I spent the better part of a decade buying MSK practices before I ever helped anyone sell one.

I founded a physiotherapy clinic group in my twenties, growing it from a single site to 36 locations. Acquisitions were a significant part of how we scaled. I would sit opposite an owner, run the numbers, and work out what I was prepared to pay, doing this more times than I can count. Aged 30, I went through my own exit to a private equity firm.

This experience and the lessons it taught me form the foundation of Verilo, the specialist brokerage firm I now run. Our team has advised on over 100 transactions representing more than £30 million in deal value. We work exclusively with health, medical and wellness business owners, sitting opposite buyers of every kind; from individual practitioners picking up their first clinic, to consolidators and private equity groups acquiring at scale.

I explain this because this article’s themes are not theoretical; they are based on practice, where we observe the same patterns and mistakes being made. The reality of what makes an MSK practice more or less valuable to a buyer is often different to its owners’ assumptions. And that value is rarely based on the things people spend money on in the months before going to market.

What a buyer is really paying for

When I was acquiring clinics, I was not looking for the nicest waiting room or the fanciest website. I was looking for something that would hold together once I had taken over. The right foundations: a loyal patient base, a team that was not built around a single person, and a local reputation that had taken years to build and could not be replicated overnight.

Those foundations pointed to something more important: a business that could run, retain patients, and generate revenue regardless of who was at the centre of it. Repeatable systems, consistent revenue, and a predictable diary. That kind of business takes years to build. When I found it, I found something genuinely worth paying for.

The mistake I kept seeing was sellers spending money on the wrong things. A new waiting room, a rebrand, a website refresh – all fine, but none of them moved the dial for me as a buyer. If a business was performing well despite a dated website or an unloved interior, I saw that as upside. Mine to capture, once I took over. Far more appealing than paying a premium for improvements the seller had already funded.

Not every buyer thinks like me, and investment is not always wasted. But the principle holds: cosmetics are easy to fix. The foundations of a business are not.

What walks out the door with you?

If I had to reduce everything about MSK practice saleability and valuation down to a single idea, it would be this: the more transferable a business is – and therefore the lower risk a buyer perceives – the higher its value and the more likely a sale. When you exit, how much of what you’ve built walks away with you? And how much stays?

The lease is a good place to start. Most buyers want security of tenure above all else – confidence that the practice can continue trading where it is. Long-term certainty reads as an asset; the absence of it creates risk. A short, rolling or unrenewed lease may feel like flexibility to a seller, but a buyer sees it differently: a problem to be priced in or resolved before exchange. If you are approaching a sale with less than three years remaining, exploring renewal or extension options is almost always worth doing, even if your own timeline is uncertain.

Brand identity follows a similar logic. A brand that patients associate with the practice rather than the person running it is transferable; one synonymous with the owner has an expiry date. Evolution should happen gradually and well in advance, creating time to establish patient associations a buyer can actually see and value.

A well-maintained, GDPR-compliant client database is also crucial. It is a transferable asset in its own right – one that gives a buyer the ability to market to existing patients, re-engage lapsed ones, and model value from day one.

Concentration risk: people and revenue

Ask MSK practice owners what their biggest asset is, and the answer is usually people. The clinicians who have built patient relationships over years, the owner whose reputation draws referrals, the contract that keeps a reliable income stream flowing. These are what make a practice valuable, but they are also what make concentration risk one of the most significant devaluers we encounter. A buyer has to price what happens if any walk away.

This concentration tends to show up in three ways: clinical team concentration, where patients follow one practitioner and leave with them; owner dependency, where the practice relies on the owner’s clinical output or reputation; and contract concentration, where a significant share of revenue ties to a single source. That last one is often the most overlooked. NHS contracts held in a rolling or holding-over position can be vulnerable to external factors, and a practice dependent on one such contract is a riskier proposition than one with a diversified private income base.

When the concentration sits with the owner, an earn-out is a partial solution. If you are willing to stay with the business through a defined transition – usually six months to two years – you can protect some of the value. The buyer is paying for continuity you are providing, and it is worth considering seriously if you are the primary clinical draw.

Where the concentration sits with an associate or employed clinician, the answer is harder. You cannot contractually guarantee a buyer your best physiotherapist will stay. The only real solution is taking time to build a team where no single departure would damage revenue.

How are you finding new patients?

For many owners, a full diary built entirely on word of mouth is a badge of honour – and, in one sense, rightly so. It speaks to clinical quality and the kind of patient trust that cannot be manufactured. But to a buyer, it raises a different question: if nothing is driving that growth deliberately, how confident can they be that it will continue?

What a buyer actually wants to know is your strategy for getting new patients consistently. Can you demonstrate someone else could do it after sale? If the answer is yes, you become considerably more attractive.

Well-documented marketing strategies, an updated Google profile, a referral partnership with a local GP, email automation for re-engaging lapsed patients, or proven paid advertising all tell a buyer growth is not accidental.

Practices that can show a strong word-of-mouth reputation and a good grasp of patient acquisition are genuinely rare, and therefore worth a premium.

The finances: what buyers actually look at

Every business is different, and value is often more art than science. It is ultimately determined by the market, by what a motivated buyer will pay. That said, we regularly see most experienced buyers follow a similar financial assessment process.

Most buyers use a multiple of adjusted EBITDA, or earnings before interest, tax, depreciation and amortisation. In plain terms, it is the underlying profit the business generates, stripped of financing and accounting decisions: what the business actually earns before the owner decides how to structure it.

Your EBITDA may be different from the profit figure on your tax return. Owners often pay themselves at non-market rates, and structure finances to minimise tax rather than demonstrate commercial value. Before a sale, these figures are normalised to reflect what a buyer would actually earn. What remains after those adjustments is your adjusted EBITDA – the number a buyer will base their offer on.

In the MSK sector, multiples typically run between three and five times EBITDA, though we have seen transactions exceed that range. What pushes a multiple higher is the combination of factors covered in this article. Buyers are essentially pricing risk. The less risk they perceive, the more they are prepared to pay. Clean, well-maintained financial records support that process – they make it straightforward for a buyer to assess the business, build confidence in the numbers, and move quickly.

Size matters

Not every practice will attract the same buyers, and turnover is one of the biggest factors in determining who comes to the table.

At around £100,000 or below, the market is limited. These businesses are typically owner-operated, harder to model financially, and appeal mainly to individual practitioners or local competitors after a bolt-on. Valuations are variable and the likelihood of completing is lower.

As turnover grows towards £250,000 to £500,000, the buyer pool widens: regional operators, multi-site acquirers, portfolio builders. Deals become more structured and valuations more predictable.

Above £500,000, things change substantially. Consolidators, smaller private equity groups and family offices enter the picture. Buyers are no longer constrained to your postcode, competition between them increases, and that competition is one of the most reliable mechanisms for improving what a seller receives.

Driving turnover is not just about building a bigger practice. It is about expanding the range of people who want to buy it.

The process matters as much as the preparation

There is a point in every sale where preparation stops being the main variable and process takes over. How a business is presented to the market, and how that process is structured and managed, shapes a significant part of the final outcome.

A well-run process creates competitive tension; with multiple credible buyers in conversation simultaneously and aware of each other, thinking tends to sharpen, conditions get clearer, and offers improve.

The data on this is compelling. Based on a study published in The Quarterly Journal of Finance, represented sellers achieve between 6 and 25% higher purchase prices than those who go to market alone. [1] Unrepresented sales are also 60 to 70% less likely to complete at all.

The reasons are fairly straightforward: fewer buyers in the room, higher emotion, avoidable problems surfacing too late, and the risk of getting too far down the road with the wrong buyer before realising it. If your primary deal falls through and there is no second or third option, you negotiate from a position of weakness. Time passes, momentum is lost, and the business often goes back to market at a discount.

Having someone who understands the sector and knows the buyer landscape is not a luxury reserved for large transactions. For most practice owners, it is one of the most significant levers available once the preparation work is done.

Build the better business first

Looking back across every transaction I have been part of – as buyer, seller, and now advisor – there is a clear pattern. The owners whose sales go well are almost always the ones who thought about transferability before it was urgent.

A settled team, clean records, a secure lease, a respected brand, predictable client acquisition… None of these things require a sale to be on the horizon. They are just what a well-run practice looks like.

Whether you plan to sell in two years or twenty, building something transferable is building something better. The exit is just one of the rewards, not the only one.

References

[1] Agrawal, A., Cooper, T., Lian, Q. and Wang, Q. (2023) ‘Does hiring M&A advisers matter for private sellers?’, The Quarterly Journal of Finance, 13(1). Available at: https://doi.org/10.1142/S2010139223500040

Recently I found myself in two very different rooms: Laing Buisson’s Out of Hospital Healthcare Conference and HETT (Health Excellence Through Technology).

Laing Buisson is a well-known health market intelligence organisation that convenes leaders from the independent and private healthcare sector, commissioners, insurers, investors and provider organisations. Conversations there tend to focus on contracts, investment, national footprint and insurer relationships.

At HETT, by contrast, the focus is digital transformation across the NHS. The language was digital maturity, AI-supported triage, interoperability and dashboards. One room spoke about capital; the other about code. Yet the direction of travel was strikingly similar: scale, standardisation and measurable productivity.

What struck me was not the difference between the two events, but the convergence in their thinking. Whether the conversation centred on investment models or digital architecture, the underlying assumptions about how healthcare should evolve were remarkably aligned. In both spaces the emphasis was on systems that could be replicated, measured and governed at scale.

Listening to these conversations, I kept returning to a simple question: where is the patient in this?

Picture it. The next patient is walking through the door and you don’t have a f*****g clue what to do with them. You just hope they don’t ask too many questions.

I know I’ve been there… have you?

Thankfully, less so in recent years, although I certainly do still have those moments! I’m experienced enough now however to openly acknowledge this and save myself the later embarrassment showing that I was winging it. An embarrassment that I endured time and time again in my early years as a physiotherapist.

“Patient’s had an ankle fusion? Hmm, not sure what that is and no real time to understand it or discuss it with my senior so to hell with it, I’ll just fall back onto pushing and rubbing it a bit.” This is the case that stands out to me when I reflect back. I cringe every time. Trying to restore movement in a joint that had been excised, packed with bone graft and held firmly together with a nail. What an idiot!

This is an uncanny representation of that fateful day!

Overconfidence in special tests, diagnosing everyone with complex biomechanical issues that existed purely in my own head and not having the foggiest idea of what would happen in the world of orthopaedics should my patient fail to improve. The list could go on.

And the way I see it, there are two possibilities here:

* I was in the bottom quartile when it came to knowledge after coming out of university and too arrogant to even think that this was a possibility.

* I was simply not prepared in the right way to be as effective, accurate or aware of my own limitations as I needed to be in the complex world of MSK.

Those who know me personally and read this will delight in telling me it’s number 1 and that they never experienced anything like what I’ve laid out above.

And to them I say; it’s okay, they’re only my feelings you’ve hurt and I’m sure they’ll heal… and also you’re lying. Experiences just like mine are extremely common. Based on the conversations I have had, I would actually go as far as to say it is the normal experience for new graduates in MSK!

But is it a sign of personal failure? Absolutely not.

It’s actually a fairly predictable situation. Yet, we seem to be okay with it as a profession; regardless of the negative impact that it has on the clinician who might experience high levels of stress, the patient who has waited months or invested their own money to come and see a specialist, or the reputation of the profession when these two previous scenarios mix and leave a sour taste in everyone’s mouth.

In this article, I want to challenge the status quo of MSK training and practice with a particular nod to the pre-registration degree, whether that be undergraduate or pre-registration masters. I will argue that it is no longer fit for purpose and can actually be counter-productive to producing good quality MSK clinicians.

In 2014, clinical pharmacist and exercise medicine champion Ann Gates spoke to Jack Chew on The Physio Matters Podcast about the need to reposition physical activity at the centre of healthcare. She described physical inactivity as a public health crisis, advocated for integrating exercise into every patient consultation, and encouraged us to view exercise as a therapeutic agent as legitimate as drugs or surgery.

Nearly 12 years later, the evidence base for exercise medicine has grown substantially and many health systems are increasingly prioritising physical activity in policy and clinical practice. In our first Core Memories feature, we assess how Ann’s insights align with current evidence and thinking in 2026, exploring where her 2014 perspectives have been supported, updated, or reframed by the research.

Exercise as Medicine: Then and Now

2014

Ann framed exercise as being akin to a pharmacological intervention; something that should be prescribed, monitored, and integrated into treatment regimens. She argued that exercise has cost-effectiveness comparable to many drugs and called for healthcare systems to see exercise as an equal partner to traditional medicine.

2026

Ann’s viewpoint has only strengthened with advancing research. Over the past decade, multiple large-scale meta-analyses and clinical guidelines have solidified what earlier researchers hinted at: exercise has measurable effects on morbidity and mortality across a range of chronic conditions.

For example:

Cardiometabolic disease: In secondary prevention and some high-risk groups, structured exercise interventions can achieve mortality outcomes comparable to drug therapy in the evidence base, and exercise-based programmes (e.g. cardiac rehabilitation) reduce cardiovascular mortality and recurrent events, though effects on all-cause mortality are more variable in contemporary trials [1,2].

Type 2 diabetes: For type 2 diabetes, physical activity is firmly positioned as a foundational component of management rather than optional advice. Contemporary NICE and American Diabetes Association guidance places structured exercise alongside pharmacotherapy from diagnosis, recognising its role in improving insulin sensitivity, lowering HbA1c (a blood test that measures blood glucose levels over the past three months), and reducing cardiovascular risk [3,4]. Meta-analyses consistently show that aerobic, resistance and combined training meaningfully reduce glycaemic markers, with combined approaches often producing the greatest benefit [5,6]. While exercise does not replace medication for most patients, it can reduce medication burden in some cases and remains one of the most powerful long-term cardiometabolic interventions available [7].

Cancer survivorship: Exercise is now embedded within survivorship care in many oncology pathways, with international guidelines recommending structured aerobic and resistance training following treatment [8,9]. Level-1 evidence, including large randomised trials such as the CHALLENGE study in colon cancer survivors, demonstrates reduced recurrence risk alongside improvements in quality of life and physical function [10]. Across tumour types, systematic reviews consistently confirm exercise as a safe, effective adjunct in post-treatment care [11].

Health organisations and clinical initiatives (e.g. Exercise is Medicine/ACSM and NHS England-aligned programmes) increasingly treat physical activity as a “vital sign” assessed in routine consultations and linked to actionable goals [12–14]. Ann’s view that exercise should be monitored like a drug has gained traction in clinical pathways and electronic medical records, where best practice is for physical activity metrics to be charted alongside markers such as blood pressure and blood glucose, although adoption remains variable.

Conclusion

The core premise of exercise medicine articulated in 2013 has been reinforced and operationalised. In 2026, it is not just progressive advocacy but a mainstream clinical priority in many healthcare systems.

Brief Interventions and ‘Making Every Contact Count’

2014

Ann emphasised brief, teachable moments within consultations: short but confident advice linking exercise to measurable health outcomes. She cautioned against treating exercise advice as a quick fix and advocated for monitoring and follow-up analogous to pharmacotherapy.

2026

This approach aligns closely with contemporary behavioural science and implementation research. Brief physical activity interventions delivered in primary care have demonstrated modest but clinically meaningful increases in activity levels, particularly when combined with goal-setting and follow-up support [15,16]. Even very short conversations, often under two minutes, can prompt behaviour change when paired with structured referral pathways or digital reinforcement [16,17].

Making Every Contact Count remains a valid and widely endorsed model within UK public health strategy [18], though modern implementation increasingly incorporates digital systems — including patient portals, remote monitoring, wearable data integration and automated messaging — to improve adherence and clinician follow-through [19].

Importantly, systematic reviews confirm a point Ann anticipated: brief advice alone is usually insufficient unless embedded within wider behaviour-change systems that include ongoing support, environmental accessibility and tailored feedback [15,20].

Current nuance

Recent work in behavioural medicine emphasises contextual tailoring; interventions are most effective when adapted to readiness to change, health literacy, socioeconomic context and cultural background [20,21].

Conclusion

Ann’s 2014 framing of brief, confident, monitored interventions anticipated current best practice. In 2026, the principle remains sound but effectiveness increasingly depends on structured follow-up and digitally enabled support systems.

Healthcare Systems, Barriers, and Equity

2014

Ann argued that healthcare systems were poorly designed to promote exercise, stressing the need for community links, clinician empowerment, and breaking down barriers that prevent physical activity.

2026

Subsequent policy frameworks increasingly reflect this thinking. The last five years have seen:

* Inclusion of physical activity targets within national strategies, including NHS Long Term Plan delivery updates and the UK Chief Medical Officers’ physical activity framework, which position prevention and activity promotion as core system priorities [22,23].

* Growth of community-linked referral schemes, including social prescribing pathways and exercise referral programmes designed to connect patients with local activity providers through primary care networks [24,25].

* Greater integration of social determinants of health into physical activity policy, with recognition that access to safe environments, green space, transport infrastructure and socioeconomic stability significantly influence participation [23,26].

However, implementation remains uneven. Despite national ambition, regional variation in service availability and infrastructure persists, and disparities in access to community programmes continue to reflect the “postcode lottery” Ann described [24,27].

A notable evolution over the past decade has been a sharper focus on health equity. Research consistently demonstrates disparities in physical activity participation by ethnicity, gender, age, disability and deprivation [26,28]. In response, targeted programmes — particularly those addressing adolescent girls, older adults and underserved communities — have demonstrated improved engagement and adherence when culturally and contextually tailored [28,29].

Conclusion

Ann’s 2014 critique of structural barriers remains valid. By 2026, however, policy frameworks are more explicitly equity-oriented and data-driven, even if delivery across systems remains inconsistent.

Research Gaps and Implementation Science

2014

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

2026

Over the past decade, research quality in exercise medicine has improved substantially. Large pragmatic trials now more commonly incorporate structured, standardised exercise protocols aligned with public health guidance, including aerobic volumes consistent with 150+ minutes per week and inclusion of resistance training components [30,31].

There has also been a marked rise in implementation science within physical activity research, focusing not only on efficacy but on scalability, system integration and real-world translation into primary and secondary care pathways [32,33]. Longer-term follow-up has become more common, with several contemporary trials and cohort extensions reporting outcomes beyond two to five years, addressing earlier concerns that exercise research relied too heavily on short-duration endpoints [34].

That said, important gaps remain. Head-to-head comparative trials between structured exercise prescriptions and procedural or invasive interventions are still relatively uncommon outside selected cardiology and oncology contexts [35]. While funding streams and international collaborations in exercise oncology and cardiometabolic health are expanding, coordinated multi-site interdisciplinary exercise medicine research remains underdeveloped compared with pharmaceutical research infrastructures [32,36].

Conclusion

Exercise medicine research is more rigorous and implementation-focused than it was in 2014. However, comparative trials and large-scale coordinated funding still trail behind other treatment areas. The evidence is stronger, but system-level integration remains incomplete.

Final Reflections

Looking back from 2026, many of Ann Gates’ perspectives from 2014 not only stood the test of time but anticipated future developments in clinical practice, research and health system design. Exercise medicine is now more embedded in routine care, brief interventions are backed by behavioural science and equity has become a central concern.

We asked Ann for her thoughts on relistening to the podcast:

“Revisiting that 2014 conversation on The Physio Matters Podcast, I’m struck by how consistent the core message remains: movement is powerful medicine. The evidence base has only strengthened over the past decade. What has evolved is our understanding of implementation and scale.

Brief advice is well evidenced, and approaches such as Make Every Contact Count have rightly embedded physical activity within routine care. But advice achieves its greatest impact when the system around it supports and sustains behaviour change.

Professional education, service design, leadership priorities and community environments determine whether movement becomes normalised or remains dependent on individual advocacy.

The next critical step is strengthening our collective change agency — redesigning healthcare so prevention is structurally embedded, aligned with the systems approach set out in the World Health Organisation’s Global Action Plan on Physical Activity.

Movement should be a mainstay in prevention, treatment and rehabilitation of ill health across the life course. The science is clear. The responsibility now is collective.”

Our collective responsibility is clear. The vision of universally integrating exercise into every consultation, ensuring consistent access to supportive community resources and developing robust comparative evidence remains a work in progress. The conversation Ann started over a decade ago continues to shape how clinicians view physical activity — not as an optional extra, but as medicine with profound, evidence-based impact.

References

* Naci H, Ioannidis JPA. Comparative effectiveness of exercise and drug interventions on mortality outcomes: meta-epidemiological study. BMJ. 2013;347:f5577. doi:10.1136/bmj.f5577.

* Dibben GO, Faulkner J, Oldridge N, Rees K, Thompson DR, Zwisler AD, Taylor RS. Exercise-based cardiac rehabilitation for coronary heart disease: a meta-analysis. Eur Heart J. 2023;44(6):452-469. doi:10.1093/eurheartj/ehac747.

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

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

* Pan B, Ge L, Xun YQ, et al. Exercise training modalities in patients with type 2 diabetes mellitus: a systematic review and network meta-analysis. Diabetes Care. 2018;41(12):2431-2439.

* Umpierre D, Ribeiro PAB, Kramer CK, et al. Physical activity advice only or structured exercise training and association with HbA1c levels in type 2 diabetes: systematic review and meta-analysis. JAMA. 2011;305(17):1790-1799.

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

* Campbell KL, Winters-Stone KM, Wiskemann J, et al. Exercise guidelines for cancer survivors: consensus statement from international multidisciplinary roundtable. Med Sci Sports Exerc. 2019;51(11):2375-2390.

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

* Courneya KS, Booth CM, Gill S, et al. Effects of a structured exercise program on disease-free survival in colon cancer survivors: the CHALLENGE randomized trial. N Engl J Med. 2024/2025.

* Segal R, Zwaal C, Green E, et al. Exercise for people with cancer: systematic review and clinical practice guideline. Curr Oncol. 2017;24(1):40-46.

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

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

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

* Orrow G, Kinmonth AL, Sanderson S, Sutton S. Effectiveness of physical activity promotion based in primary care: systematic review and meta-analysis. BMJ. 2012;344:e1389.

* O’Brien N, McDonald S, Araujo-Soares V, et al. The effectiveness of physical activity interventions in primary care: systematic review. Br J Sports Med.

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

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

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

* Michie S, van Stralen MM, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci. 2011;6:42.

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

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

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

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

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

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

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

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

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

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

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

* Glasgow RE, Harden SM, Gaglio B, et al. RE-AIM planning and evaluation framework: adapting to new science and practice with a 20-year review. Front Public Health. 2019.

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

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

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

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

Expertise is special skill or knowledge that is acquired by training, study, or practice.

I follow an Orthopaedic surgeon from the US who is of a similar vintage and much of what he posts aligns with my current thinking. I like his posts because they ooze expertise. He is extremely considered when it comes to non-operative care and he himself states how much less he operates these days, as he has become more experienced.

Yesterday, I met an extremely experienced health entrepreneur who’s worked on the business side of healthcare for decades. We were discussing how I am managing the latter part of a surgical career.

I was explaining that I don’t learn a huge amount from additional surgical procedures these days but I still learn an immense amount from seeing my patients. Don’t get me wrong, I’m not giving up surgery at all. I still see patients regularly that really make me have to think hard. The harder I think, the less I operate. Why is it that the more expertise I have, the less I operate?

It reminded me I had got thinking about expertise - there I go again – as far back as 2012. My question was, ‘can patient forums offer expertise?’ so I started looking at them online. I came across people with a condition who would have had plenty of experience or ‘practice’ in living with their condition. Many would have become very knowledgeable compared to the general population. There were, in addition, many who commented and gave advice that was way out of their lane of training. I don’t want to single out any allied health professionals but there were some who would have been trained for example in anatomy and manual therapies but virtually nothing to suggest they were people with the right expertise to advise on getting an MRI scan. The problem was that these two groups may have had huge experience of practice within MSK but that experience was not matched by training and study in the subject. Exposure without prior study, learning and reflection could not be called expertise.

I started to think about where expertise sits in the treatment pathway. I followed what we all do from the moment we start seeing a patient. I came up with a progression from acquisition of many single points of data e.g. twisted knee, medial pain, medial tenderness, swelling. All those data points when put together assume a pattern leading to information e.g. MCL tear, meniscus tear, osteoarthritis. That list is unranked i.e. equal weight is given to all diagnoses. This is where it then starts to get interesting. When that data and information is viewed by someone with knowledge and expertise, they can start to rank them into a list that floats the most likely diagnosis to the top of the pile. The application of training, study and practice improves the ranking. They draw on prior knowledge and experience from exposure to start to see the patterns. Without this, treatment plans are like throwing spaghetti at the wall to see what sticks. In other words, a bit hit and miss. A bit like when we all did our first day at work and floundered to apply our study and training in a meaningful way. Those of you reading this who have qualified will remember how poorly equipped we all were on that very first day.

So back to my original question: can patient forums offer expertise?

Dynamometry and assessment of performance are hot topics right now and with the drive to provide data-driven decisions in clinical practice, you can see why rehab professionals are seeking tools to capture this information.

A couple of years ago I had the pleasure of writing an article for MSK Mag [1], covering some of the fundamental aspects of dynamometry, assessment of performance and measurement error. We explored perhaps an uncomfortable truth:

‘Just because you have a number doesn’t mean it represents reality’

and a few ways to improve measurement accuracy. Hopefully readers were left with the take-home message that time is well invested into their measurement protocols to minimise measurement error, to generate useful data, and of course strategies on how to achieve this.

In this article, we’re going to address the other important part of the equation - the measurement tool itself. I’ll provide a simple framework to help you identify the device that’s right for your setting, along with a completely free online comparison tool to scrutinise devices against the specifications that matter. More on that in a bit.

Why Measurement Matters

Let’s just roll back a bit first and revisit the question: is the measurement of muscle performance, such as strength and rate of force development (RFD), important? Clearly I think so but here are a few reasons why obtaining (accurate) objective measurements of parameters like muscle force can be useful:

Table 1: The potential utility of objective data

The Problem After Deciding to Measure

Once you’ve rationalised your decision to test, honing your measurement skills addresses only part of the issue; the other part is the device itself and whether or not it’s fit for purpose. After reading this article, I want to leave you with a clear idea of some of the critical things to look for when selecting (or using) a dynamometer. For the purpose of this article we’re focusing on hand-held dynamometers (HHDs), but the considerations are applicable to most measurement devices.

Given the considerable variation in technical specifications between devices, a resource that provides side-by-side comparisons would be super useful to help you make an informed choice on purchasing or to see how your device stacks up against these critical metrics. So I created one.

The Need For A HHD Information Repository, With Guidance

I’ve interacted with thousands of therapists across the globe via my S&C teaching, and assessment of performance is an important part of this topic. Without fail, the most frequently asked question I receive is:

“Which dynamometer should I buy?”

Ten years ago the problem was lack of access to measurement tools. Now, the prolific rise in the number of HHDs and other devices makes “Which dynamometer should I buy?” a far more difficult question for the busy clinician to answer. Truth is, there is no single best dynamometer, nor is there a single unbiased and credible, centralised source of information on these measurement devices. So, I set out to create one - to arm clinicians with the critical information to help them navigate through the cacophony of information and marketing claims. In doing so, clinicians can identify the right dynamometer for their setting and avoid making decisions solely based on:

* Which device colleagues use

* Which device is the cheapest

* The device with the most impressive marketing

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

Note of Caution

I realise that some discerning clinicians may diligently trawl the literature for publications on HHDs, in particular searching for reports on the reliability of devices. This is a commendable feat, however it may not deliver the answer as I highlight in my recent (open access) paper [2].

I took a phone call from a friend this month. She’s been called up for HCPC audit and we both run very similar sole practitioner clinics.

A great deal of my replies to her questions about whether I had x, y or z policy in place were “erm… no?” Sure, I have consent forms for patients and a plan in place for the patient who comes in with unexplained bladder retention and bilateral leg pain… but you want to see my non-clinical policies? Written down? Give me 2–3 working days and I’ll, um, unearth them.

My friend was dubious about this. For some reason - and perhaps it’s because we’re all encouraged to project this image - she presumed I was running the perfect clinic. Policy after policy filed alphabetically in a folder, always to hand. We have so much in common, but this folder - and my apparent drive to have created and maintained it - is our great divider.

This folder does not exist.

Somewhat related, I am currently reading a book called Doppelganger by Naomi Klein. Klein is a journalist and documentary-maker and also wrote the excellent Shock Doctrine about how governments use fear within populations. Klein is frequently confused online with another Naomi - Naomi Wolf - who has built a name and reputation as a conspiracy theorist and mass spreader of misinformation. It is - and I am merely paraphrasing Klein here - not ideal.

In MSK, we all have our doppelgängers. Sometimes they look like us - only much, much better. And sometimes they’re just like us, only clearly getting it wrong. They rely too heavily on manual therapy, whereas we are, of course, more enlightened. Or perhaps they’re a totally hands-off maniac, while we sit comfortably in the skilled middle.

Klein uses the example of her dog, Smoke, catching a glimpse of himself in a glass door and barking ferociously. ‘And this is the catch-22 of confronting your doppelganger’, writes Klein. ‘Bark all you want, but you inevitably end up confronting yourself’.

This month’s MSKMag is full of these reflections: versions of us, past and present, held up for critique.

Our new feature looks exactly like us…only from 2014. We hold The Physio Matters Podcast Episode 10 featuring Ann Gates speaking on exercise promotion to scrutiny to see if the messages still hold true. Check it out in Core Memories.

If you’ve ever been on a ski forum online and thought wow, that sounds like Orthopaedic surgeon Jonathan Bell giving advice! It wasn’t his doppelganger, it was him. And he’s back to talk about expertise and why the more of it he gathers, the less he’s reaching for the scalpel. Read all about it in ‘What is Expertise?’

If you can’t tell one dynamometer apart from the next, Claire Minshull’s piece ‘The Best Dynamometer for Clinical Practice’ and her associated new website is for you.

If you’ve ever thought that physiotherapy graduates should look a little less identical and a whole lot more specialised from the off, Jeff Morton is putting forward his case for MSK to be a separate degree in ‘Trained to Struggle’.

Katie Knapton has been to two conferences of late, covering digital transformation in the NHS and investment - but while the conference themes might have looked comparable, there was one vital thing missing. Find out what in ‘Industrialised Rehabilitation’.

And if you’re envious of your doppelganger who just sold their clinic, check out our article by Verilo’s Joshua Catlett ‘How To Build Something Worth Selling’.

Whether it’s our past ideas, our professional identity, or the clinics we build, we’re not really arguing with something new. Just a version of ourselves we’d rather not see too clearly.

Chewy and Jim are back and so is the theme tune. Now I am not usually one to call out Chewy’s mum for bias but apparently she is in a grump about the lyrics. Yes maybe we do omit ‘Chewy’s dashing looks’ but there is reference to his ‘gags’ which of course are absolutely dreadful and often unpublishable trash.

Chewy and Jim is best watched in full via the video above (so you can check out Jim’s dashing looks) or you can listen on the usual podcast players.

In this recording, Chewy and Jim cover a lot of ground relating to clinicians identity, conflicts of interest and the perils of social media.

Are We Accidentally Creating a Two-Tier MSK System?

Every few years, MSK seems to rediscover an old argument and insist it’s new. Hands-on versus hands-off. Manual therapy versus exercise. Biomedical versus biopsychosocial. Pick your side, sharpen your acupuncture needles, and head to social media.

But while everyone is busy refighting those wars, a quieter shift appears to be happening under our noses. One that’s less about techniques and more about identity. Not how we treat, but what kind of clinician we are becoming.

Not in the sense of ‘good’ and ‘bad’ clinicians, or evidence-based obsessives versus charlatans. But in the sense of two diverging professional trajectories: the interventionalist and the health-coach generalist.

“I almost saw it as being those that were really trying to hark back to diagnostic specificity [that were getting more into interventions].” - Chewy

Jim asks Chewy this very interesting and insightful question: are we drifting towards a two-tier MSK system?

“I think that there maybe are the crap ends of each of those spectrums.” - Chewy

When we talk about conflicts of interest, we tend to think about obvious commercial ones: paid endorsements, sponsored products, affiliate links.

But many of the most influential conflicts in MSK are reputational rather than obvious receipt of piles of cash.

“Strength and conditioning I see a lot of people doubling down on because it’s grabbing attention.” - Jim

Is Two-Tier MSK Inevitable?

Perhaps some degree of stratification is unavoidable. We do need interventionists. We do need clinicians with advanced technical skills. And we do need generalists who can guide patients through long-term behaviour change.

“The multi-disciplinary clinics are doing very well because they can have some specific components to but also provide a more general service where you can cross refer.” - Jim

Good MSK care exhausts proportionate options before escalation. It recognises uncertainty. It manages expectations. It acknowledges bias. It remains flexible enough to change course without defending an identity.

Of course clinical topics aren’t Jim’s only strengths; he can also make fantastic puns using Chewy’s name. Get involved in the features ‘Would Chew Rather?’ And ‘Who Are Chew?’

Would Chew Rather see lots of complex patients every 30 minutes or just one person for a whole week? And who would Chew like to have dinner with? The answers will likely surprise you… Let us know yours.

If you have any ‘Would Chew Rather?’ or ‘Who Are Chew?’ questions put them in the comments or email them to us [email protected]

Over the past decade few developments have reshaped UK musculoskeletal (MSK) care as profoundly as the rise of First Contact Practitioners (FCPs) in primary care. What began as a pragmatic response to workforce pressure has quietly evolved into something far more significant: advanced-level clinical decision-making at the very forefront of the system.

In many ways FCPs have changed the front door of the NHS.

Patients now access specialist MSK expertise earlier. GPs are better supported. Pathways move faster. Risk is managed closer to the point of presentation. When the model works well, the whole system works smarter.

But as the FCP role has expanded, it has become increasingly clear that the expectations placed on many FCPs now look very much like those of advanced practitioners, even though, formally, the role is rarely defined that way.

For me, that creates a tension within the profession.

Because the future of MSK care will not be shaped simply by how many FCPs we employ, but by how well we develop, support, and lead the clinicians working at the front line of primary care, and how well the rest of the system keeps pace with what that front line now requires.

From workforce solution to advanced clinical reality

The FCP model was born out of necessity. General practice was under intense pressure. MSK presentations were consuming huge clinical capacity. Waiting lists were growing. Patients were often being referred into pathways that felt slow, fragmented, and overly medicalised.

Putting experienced MSK clinicians at the point of first contact made sense, and in many places it has worked brilliantly.

Today, FCPs are routinely:

* Assessing undifferentiated presentations

* Identifying serious pathology early

* Making referral decisions

* Managing clinical uncertainty in real time

* Shaping patient beliefs at the very start of their journey

* Influencing practice-wide MSK decision-making.

This is not just triage or filtering demand. This is advanced-level practice in one of the most pressured environments in the NHS.

MSK in primary care has become a setting where judgement matters as much as skill. Where pattern recognition, risk stratification, and professional confidence are tested daily. Where the first conversation often determines the entire trajectory of someone’s care.

And yet despite this, we still tend to talk about FCPs as if they are primarily a service solution rather than a professional group operating at (or rapidly moving towards) advanced practice. That gap between what the role is called and what the role actually requires should not be ignored.

What’s working well

Across the UK, there are outstanding examples of FCP-led MSK services. Where advanced-level practice is properly supported in primary care, three things consistently stand out.

1. Right expertise, right time

When skilled MSK clinicians see patients first, the impact is immediate. We see fewer unnecessary scans, more appropriate referrals, earlier reassurance, and high levels of patient satisfaction [1]. Having specialist MSK expertise at the front door reshapes what ‘good MSK care’ looks like.

2. Stability in the grey zones

Primary care is full of grey zones. MSK presentations are rarely neat. Pain is complex. Fear is common. Red flag pathologies are rare, but very much there.

What experienced clinicians bring here is not certainty, but calm judgement. Confidence that comes from experience, pattern recognition, and knowing when not to act.

That confidence reduces defensive referrals, unnecessary imaging, clinician anxiety, and patient fear. In this way, advanced MSK practice does more than assess and manage conditions. It helps to stabilise the system.

3. FCPs as translators of MSK thinking

One of the most underestimated contributions of FCPs is their educational influence.

Every day, they reframe beliefs and myths. They support MDT colleagues with MSK reasoning. They influence how practices triage.

They translate specialist MSK knowledge across primary care, and that influence reaches far beyond the clinic room.

The tension we rarely name

Here is the issue we do not talk about openly enough.

FCPs are not formally classed as advanced practitioners, yet many are expected to work at an advanced level.

That matters.

Because the responsibilities placed on FCPs increasingly include:

* Holding undifferentiated clinical risk

* Making decisions with downstream consequences

* Acting as senior MSK decision-makers within practices

* Influencing referral behaviour and shaping MSK pathways.

These are not entry-level expectations. They are hallmarks of advanced practice.

And yet, in many parts of the system, FCP roles are still viewed as sitting somewhere between senior clinician and advanced practitioner - without the clarity, structure, or investment that true advanced practice demands.

The result is predictable.

Some clinicians grow and excel through experience, self-directed learning, mentorship, and/or higher education. Others are placed into roles that quietly outpace their readiness.

And that leads to another uncomfortable truth.

Quality varies. A lot.

Across the UK, the quality of FCP practice varies significantly.

There are FCPs working at an exceptional level. Clinically confident, comfortable with risk, and deeply influential within their practices.

And there are others, committed and capable clinicians, who have been placed into FCP roles before they were truly ready for the responsibility the role now carries [2].

This is not a criticism of individuals. It is a system design problem.

The rapid growth of FCP services was driven by urgency. Access had to improve quickly. Roles expanded at pace. In many areas, this meant accelerated transitions, variable training standards, inconsistent supervision, and very different interpretations of what ‘FCP-ready’ actually means.

The consequence is predictable: a wide spectrum of practice under a single job title.

At one end, clinicians confidently manage complexity and shape MSK pathways. At the other, clinicians are still consolidating core reasoning while balancing advanced-level risk.

Both are called FCPs. But they are not working at the same level of practice, and the system often behaves as if they are.

Don’t get me wrong, variation exists in every profession. But in primary care, its impact is amplified. When FCP practice is done well, it reduces harm, cost, and fear. When it is done prematurely, it increases all three.

But there is another layer to this that we do not talk about enough. Even when the FCP decision is clinically sound, the rest of the system does not always keep up.

The rest of the MSK pathway is not up to speed

Large parts of the MSK system have not evolved at the same rate as FCP provision. Across the UK, outpatient physiotherapy services vary enormously in quality, resource, and capacity.

In many settings, clinicians are working exceptionally hard within significant constraints. They are delivering care in overstretched services, under intense time pressure, and with limited access to facilities or follow-up [3].

The issue is the system they are working within.

In some areas, patients are seen quickly. They have access to proper gym equipment. They receive structured rehabilitation programmes. They are supported to progress, not just given advice and discharged.

In others, waiting lists are long. Appointments are brief. Resources are minimal. Patients report being ‘handed a sheet of paper’ and told to get on with it.

And then they come back to primary care saying they have ‘failed physiotherapy’.

They say the exercises did not work.They say nothing changed.They ask, “What now?”

They are often labelled as ‘non-responders’.

But frequently, what has really failed is not physiotherapy itself. It is the quality, intensity, and individualisation of the rehabilitation they were given.

This creates an unhelpful dynamic.

The FCP makes a reasonable physiotherapy referral.The patient waits months.They receive minimal intervention.They return to primary care saying physio has not worked.And now the pressure to escalate, request imaging, inject, or refer increases.

Not because the condition demands it. But because the rehabilitation pathway was not fit for purpose.

This puts FCPs in an impossible position.

They are working in a system where downstream services vary widely in quality, waiting lists undermine early intervention, rehabilitation standards are inconsistent, and patient expectations are shaped by poor prior experiences.

That means FCPs are not just making clinical decisions. They are compensating for system weaknesses. They are trying to hold a line on conservative care in a system that does not always deliver conservative care properly.

That is not a small thing.

It requires judgement, resilience, and leadership. Advanced-level practice.

What needs to change next?

The uncomfortable reality is this.

We have built advanced responsibilities at the front door, but not consistently built advanced pathways behind it. And we have built advanced expectations of FCPs without consistently building advanced support around them.

That is not solved by telling FCPs to complete a postgraduate course alone.

It is solved by designing better systems and providing appropriate, ongoing support and education.

That means:

* Clearer national expectations of what ‘FCP-ready’ actually means

* Honest recognition that many FCP roles are, in practice, advanced practice roles

* Protected time for development rather than pure service delivery

* Formal mentorship and supervision as standard

* More consistent standards for MSK rehabilitation downstream

* Better communication between primary care, physiotherapy services, and interface clinics.

Advanced practice should be earned through genuine development, not assumed through appointment or credentials alone.

And advanced care should be delivered through proper systems, not heroic individual effort.

A quiet signal of what’s coming next.

There is a growing recognition that advanced MSK practice development needs regular support and learning opportunities:

Exposure to complex cases and advanced clinical reasoning.Support with managing uncertainty.Leadership development grounded in real-world practice.

Not just isolated training days, but ongoing programmes, regular CPD opportunities and resources and communities: spaces designed not simply to update skills, but to shape professional identity, leadership, and influence.

Something is beginning to form in that space.

Work is underway to create a platform specifically designed to support clinicians operating at, or working towards, advanced-level MSK practice. A platform that brings together monthly webinars, a substantial on-demand content library, courses, events, and a community focused on the realities of advanced practice.

This work is being led by yours truly, not as someone standing outside the profession, but as a clinician working within it, facing the same uncertainty, responsibility, and complexity as others in these roles.

The intention is simple: to help create the kind of space that many advanced practitioners wish had existed earlier in their careers, and one that remains relevant as practice continues to evolve.

That work is taking shape as Physio Matters Advanced Practice (PMAP). Watch this space.

References

* Downie F, McRitchie C, Monteith W, Turner H. Physiotherapist as an alternative to a GP for musculoskeletal conditions: a 2-year service evaluation of UK primary care data. British Journal of General Practice [Internet]. 2019 Apr 8;69(682):e314–20. Available from: https://bjgp.org/content/69/682/e314

* Hayward-Giles S. First contact physiotherapy: challenges and opportunities [Internet]. The Chartered Society of Physiotherapy. 2025. Available from: https://www.csp.org.uk/frontline/article/first-contact-physiotherapy-challenges-opportunities

* NHS waiting lists rise demonstrates need for graduate physio job guarantee [Internet]. The Chartered Society of Physiotherapy. 2025. Available from: https://www.csp.org.uk/news/2025-08-14-nhs-waiting-lists-rise-demonstrates-need-graduate-physio-job-guarantee

Urinary incontinence is often seen as something that belongs firmly in the realms of pelvic health. When I worked solely in MSK, I rarely asked about it unless I was screening for cauda equina. If I am honest, I hoped for a straightforward “no”. If someone did say yes, I clarified that it was not new or acute, reassured myself it was not a red flag, and moved on. I am sure I was not alone in that approach.

The reality is that urinary incontinence is very common.

In the UK, around 14 million people live with some form of urinary incontinence. Roughly one in three women and up to one in ten men will experience it during their lifetime. In female athletes the numbers are higher still, particularly in impact sport. It is not rare or niche; it is present in many of the people we already treat.

Broadly, we see two main patterns. Stress urinary incontinence occurs with effort such as coughing, jumping, lifting or sprinting. Urge urinary incontinence is leakage that follows a strong, sudden need to void that is difficult to delay. Many people experience a mix of both.

Stress urinary incontinence is multifactorial. Pelvic floor muscle weakness is one contributor, but not the only one. Parity, hormonal changes, connective tissue laxity, hypermobility and altered neuromuscular timing all play a role. Oestrogen deficiency in the peri- and postmenopausal years can reduce urethral closure pressure and tissue integrity. In younger athletic populations, high training loads without adequate recovery may influence tissue resilience.

So why does this matter in MSK?