Chiropractic manipulation has been around long enough to be both revered and misunderstood in equal measure. For some, it’s the magic button that fixes everything from a sore back to a bad mood. For others, it’s a mysterious cracking ritual that must be avoided at all costs. In truth, spinal and extremity manipulation is a highly skilled, evidence-informed tool, but like any powerful tool, it requires wisdom, restraint, and a healthy dose of common sense.

Let’s start with a few common misconceptions. No, we don’t ‘put bones back in’. Your vertebra doesn’t go missing in action and need clicking back into place. And no, your spine is not now ‘aligned with the universe’. It’s a joint, not a solar system. And despite the internet’s enthusiasm, not every click, crack, or pop you see on social media is therapeutic; sometimes it’s just noise, clickbait, or a little harmless ASMR for the viewer and listener; best enjoyed with some doom-scrolling.

One of the reasons manipulation attracts such polarised opinions is that it produces an immediate, tangible sensation. Patients feel something happen. Clinicians hear something happen. In a healthcare world increasingly driven by slow-burn outcomes and delayed gratification, that immediacy can be both its greatest strength and its biggest trap. Humans are wired to associate instant feedback with effectiveness, even when long-term outcomes may tell a more nuanced story. A click can feel convincing; a quiet improvement over six weeks of rehab, less so. This doesn’t make manipulation ineffective, far from it, but it does mean we must be careful not to confuse impact with importance.

There’s also a performance element that’s hard to ignore. Manipulation looks confident. It looks decisive. It looks like you know what you’re doing, which is precisely why it should never be used to mask uncertainty. The real skill isn’t delivering a thrust; it’s being able to explain why you are or aren’t using one. Confidence built on clarity will always outlast confidence built on theatrics. Patients don’t need us to look impressive; they need us to be right often enough, honest always, and reflective when things don’t go to plan.

I’ve built a career around this exceptional tool, where I know the hands-on skills I’ve delivered, with precision, intent, and certainty, have genuinely helped lead patients out of pain. The change can be immediate. Shoulders drop. Faces soften. Someone stands up straighter than they walked in. Painkillers stopped. In those moments, it’s tempting to believe you’ve found the answer. The only answer, one might think. And sometimes, that confidence becomes contagious, for not only for the patient, but also the practitioner.

I’ve watched patients return with a familiar look: hopeful, expectant, already positioning themselves on the table before I’ve finished asking how they’ve been. “that crack was unreal!”, they’ll say. “That’s what fixed it last time.” Cue the affectionate but dangerous mythology, and the uphill task of convincing them to engage in load management, to change their habits, to take exercise snacks in the day, that will also help them.

That’s when the line becomes blurred. Not because manipulation is ineffective - far from it - but because it worked so well that it risks becoming the whole story rather than part of it. When relief is rapid and repeatable, patients can start chasing the sensation rather than the outcome. And if we’re not careful, clinicians can start supplying it, mistaking patient satisfaction for patient progress.

This is where certainty needs tempering with responsibility. The same confidence that makes manipulation powerful is the same confidence that can quietly undermine long-term resilience if it isn’t paired with education and restraint. Because our job isn’t to create repeat customers for a noise or a feeling, it’s to create people who don’t need us quite so much.

Used well, manipulation can open a door. Used carelessly, it can become a revolving one.

A chiropractor’s duty of care means knowing when not to adjust. That’s right - sometimes the best adjustment is no adjustment at all. Think of it like cooking: just because you own a spice rack doesn’t mean every dish needs a tablespoon of chilli powder. We’re responsible for screening, assessing, and deciding whether manipulation is appropriate, or whether other treatments (rehab, soft tissue therapy, education) might serve the patient better.

Part of the confusion stems from terminology. In chiropractic circles you’ll hear ‘adjustment’, in physio circles ‘manipulation’, and in sports medicine ‘high-velocity low-amplitude thrust’ (HVLA), because nothing says fun like a name that sounds like a rocket launch. Ultimately, the principles are the same: skilled joint mobilisation to restore motion, reduce pain, and improve function. In musculoskeletal (MSK) practice and elite sports, it’s often used as part of a wider plan, not a solo act.

Context matters enormously. In elite sport, for example, manipulation may be used to restore short-term range of motion or reduce protective tone or stimulate muscle proprioception before training or competition, in full knowledge that it’s a temporary window rather than a permanent fix. In primary care, the same technique might be used far more sparingly, prioritising reassurance, load management, and long-term self-efficacy instead. The technique hasn’t changed, the reason for using it has. This distinction is often lost in online debates, where manipulation is discussed as though it exists in a vacuum rather than within a broader clinical ecosystem.

Equally important is recognising the difference between can and should. Many joints are manipulable; far fewer genuinely need it. Clinical maturity often shows itself not in how many techniques you’ve mastered, but in how many you consciously choose not to use. This restraint isn’t a loss of skill, it’s evidence of it.

Now, let’s talk about the ‘gurus’. Many of us were taught that THE adjustment is the ultimate, all-powerful treatment. And yes, done well, it can be transformative. But as a wise man in red and blue Lycra once said: “With great power comes great responsibility.” Spiderman probably wasn’t talking about the lumbosacral junction, but the point stands. If all you have is an adjustment, every problem starts to look like a subluxation, or, as the saying goes, if you’re a hammer, everything is a nail.

Growing up, I had a very simple engineering lesson passed down from my grandfather, Chuck. He worked out of a garage with a handwritten sign taped to the door: “Moving too much? Weld it. Not moving enough? WD-40. Otherwise, leave it alone.” Alongside it sat his personal motto: “If it ain’t broken, don’t fix it.” As crude as it sounds, that algorithm has served me surprisingly well in understanding when and why I use SMT. In my early chiropractic training, there were moments when the internal monologue behind an adjustment felt suspiciously like: “Why am I manipulating this part of the spine? Well… because chiropractic.” It wasn’t until I began applying my grandfather’s logic: intervention only when justified, that manipulation stopped being a default behaviour and started becoming a considered, rational clinical choice.

As clinicians develop, there’s often a quiet shift from technique obsession to outcome obsession. Early on, it’s tempting to chase the perfect setup, the perfect contact, the perfect cavitation or click. Later, the questions change: Did this meaningfully alter the patient’s symptoms? Did it help them move, train, sleep, or cope better? Did it move the plan forward? If the answer is no, then the elegance of the thrust becomes largely irrelevant. Manipulation earns its place not by tradition or identity, but by utility.

This is where reflective practice becomes essential. Reviewing outcomes, retesting, and being willing to say “that didn’t work as hoped” separates evidence-informed clinicians from ritual-based ones. Manipulation should survive scrutiny; if it doesn’t, it should be modified, replaced, or dropped altogether. Diagnostically the outcomes (or lack of) post-manipulation help to tell an important story of your patient.

And that brings us neatly to the idea of ‘bang for buck’. In patient management, it’s about choosing interventions that deliver the greatest benefit relative to effort, risk, and cost. Just because a treatment exists or your own practitioner bias exists, it doesn’t mean it deserves top billing in every plan. Sometimes a well-placed adjustment will provide immediate relief and functional improvement, but other times targeted exercises, posture education, or soft tissue work will give more lasting results for less fuss. A savvy clinician weighs the options, considers the patient’s goals and context, and selects what truly gives the most value; not what simply makes the loudest crack. It’s a reminder that effectiveness is about outcomes, not theatrics - patients deserve more than just one cute thing.

Let’s not leave patient safety out of this article either. A good chiropractor doesn’t just click and hope for the best, they continually evaluate its appropriateness. We explain what we’ve found, rule in or rule out manipulation as appropriate, and give patients clear advice on what to expect, including when to come back, and more importantly, provide the safety net of when to seek urgent medical help. Done properly, this process builds trust and ensures manipulation is used at the right time, for the right reason, in the right person. The wise words of my former boss, Ulrik Sandström, still resonate with me: “It works for some of the people, some of the time”, much like any other therapy, not just spinal manipulation.

Perhaps the most underappreciated role of manipulation is its ability to open a conversation rather than bring it to a close. When used appropriately, it can help build trust, reduce fear, and give patients a sense of momentum early in their care. However, that moment should act as a doorway, not a destination. The real work often happens afterwards — in the exercises patients actually complete, the beliefs they quietly reframe, and the confidence they rebuild in their own bodies.

Too often, this is undermined by what can only be described as a verbal chiropractic beat-down. Patients are told, “Your head is too far forward”, “Your hips are rotated inwards”, “You’ve got the flattest feet I’ve ever seen”, or “This muscle isn’t working — it’s very weak”. Faced with a list of perceived faults, it’s hardly surprising that the default conclusion becomes that spinal manipulation is the only solution. The problem isn’t the intervention itself, but the narrative built around it.

I often say to students when teaching communication skills: if your patient wasn’t body-dysmorphic when they walked in, there’s a real risk they will be by the time they leave. This kind of fear-based messaging is rarely ill-intentioned, but it reinforces a passive model of care. It keeps patients dependent on being ‘fixed’, rather than empowering them through a more active, collaborative, and resilient approach to recovery.

When framed this way, manipulation stops being the headline act and becomes what it arguably always should have been: a supporting character. Useful, sometimes impressive, occasionally indispensable, but never the entire story and a very essential working cog.

In short: manipulation is neither mystical nor malevolent. It’s a tool - a powerful one at that - but not the only one in the box. Our job is to use it wisely, avoid overuse, and remember that sometimes the most heroic thing we can do for a patient is advise, reassure, educate, signpost…or just leave it be.

Neurodiversity is estimated to affect 15% of the population [1], and despite a similar cause and a great deal of crossover, there are a variety of different diagnoses and expression of traits. Although many neurodiverse profiles are spiky by neurotypical standards, stigmatising terms implying severe disability such as ‘idiot savant’ have thankfully fallen out of use. A spiky profile means there are areas where ability is very high but others where natural ability is very low (when compared to a neurotypical normal range; an important caveat). Many neurodiverse individuals struggle with similar aspects of life because they are expected to conform to societal expectations and etiquette based on neurotypical norms, not neurodiverse ones: and the struggle to fit in whilst hiding your authentic self is exhausting and can lead to overwhelm and dysregulated behaviour. [2]

With neurodiversity deriving from a difference in the detection and transmission of sensory input, it’s no surprise that there’s a large crossover with hypermobility. Less ascending information due to less resistant tissues means the gain is turned up to get enough information to coordinate and perform physical function. The brain will listen harder, gaining more information at greater volume but with less specificity than in neurotypicals. Other senses can be used to compensate (e.g. visual feedback for balance and auditory feedback from heel strike), but these make the performance of function much more concentrated and effortful. The hypermobile patient always walks on sand, never pavement. Also, the necessity of having much more input across the board, to get the information you need, means processing and reaction times can be slower as the system takes longer to filter out the relevant from the irrelevant. And with this increase in volume across the board, it’s no wonder the rates of chronic pain are so much higher. [3] If we expand this model of hypermobility to all mental and physical functions relying on sensory input and feedback, you start to get some idea of the day to day struggles neurodivergent people face.

On the plus side, the sacrifice of speed for detail means neurodiverse individuals will often see the world differently and more completely, so it should be no surprise that a higher percentage of workers in innovation and the creative industries identify as neurodiverse. [4]

In 2011 I took a year out to study for an MSc in Loughborough. At a crossroads in my career, I had become bored and a little disillusioned as a clinician and wanted to step into something new for a while.

When I announced my plans to study for an MSc in Ergonomics, my physio colleagues were perplexed as to how studying someone’s desk set up could possibly be stretched out over the course of an academic year, never mind how it might result in being awarded a postgraduate degree!

I wasn’t sure whether to be amused, insulted or frustrated.

I was mildly amused that my colleagues genuinely thought that I was taking a year out to study this limited topic, a little insulted that they thought I really was that boring but perhaps more frustrated at the tendency of my profession to view things through a reductionist lens. But then again, Google seems to agree with my colleagues’ view, as a quick search of the term returns a plethora of information about the dangers of sitting, lifting or even sleeping in the ‘wrong’ posture.

Ergonomics is in fact the science of designing things (jobs, products, systems and environments) to allow people to work safely, efficiently and comfortably. To reduce this whole discipline to ‘that’ diagram demonstrating the ‘correct’ way to sit and stare at a computer screen doesn’t merely oversimplify the field but is incorrect. Most ergonomists will tell you that as dynamic beings designed to move, the best posture is, in fact, the next posture!

The truth is, those of us working within musculoskeletal pain can learn a great deal from Ergonomics, but it has nothing to do with posture or the correct way to lift a box. Far from studying one thing in detail, embarking on this MSc taught me about a range of topics, but more than that, it shifted my thinking and altered my career path. But more of that later.

The course initially appealed to me because there was a module entitled ‘Product Design’ and I thought that it might allow me to combine my knowledge of human anatomy and function with an ambition to do something a little more creative. On that front, I was to be disappointed. Even though the course was based in the Design school, and Ergonomics certainly underpins the design and development of many products, development of which demands robust research processes, a grasp of statistics is perhaps more valuable than creative flair.

But that’s not to say that my year at Loughborough was all data patterns and standard deviations. Before I get into the part of Ergonomics that I really fell in love with - the part that changed my thinking, and my career path as a physiotherapist - I would like to mention some of the great stuff that I did as part of my Masters year at Loughborough with the aim of giving some insight into such a varied and interesting speciality; one that is all around us, every day, without us often even knowing.

Environmental Ergonomics gave me the opportunity to work on some fascinating projects spending time testing different objects in the wind tunnels in the labs at the university, as well as travelling to Portsmouth to assess sound levels at a rehearsal of the Band of the Royal Marines. Temperature, airflow, noise levels: those are all ergonomic factors.

We’ve all heard the following words before and if we’re honest, probably even said them ourselves:

“Don’t worry, I’ll do my exercises at home.”“I’ve got an incredible idea for a new venture.”“I really need to spend more time on the business, not just in it.”

They’re statements of optimism and enthusiasm, small bursts of conviction that feel productive. But more often than not, they don’t lead to the outcomes we expect.

We can all relate to the patients who fall behind on their rehab, leaders who struggle to make impact, or aspiring entrepreneurs with great ideas that stay on the shelf collecting dust.

Why does this occur? Because of the intention–action gap. The space and disconnect between what people intend to do and what actually gets done.

Good intentions are wonderful, but they don’t create results. And while this may sound painfully obvious, it’s one of the most overlooked truths in human performance and business alike. Simplicity is deceptive, especially when it challenges our human behaviour.

In musculoskeletal rehab, leadership, and entrepreneurship, we consistently see people substitute the feeling of intention for the discipline of execution. ‘Busyness’ becomes the narrative, output masquerades as outcome, and genuine progress quietly slips out of reach.

So, what’s the antidote to consider? Over the past year, I’ve continued to focus on a deceptively simple, three-part framework that has clarified how to bridge the gap between good intentions and real results:

1. Clarity of outcome

Be explicit about where you want to end up. What specifically do you want to achieve and, just as importantly, how will you know when you’ve reached it?

Most of the time I talk about recognition of Rheumatological diseases that have developed and require onward referral; it has become my schtick. Reasonably many people ask me about people they work with who have already been diagnosed or don’t meet criteria for onward referral but have risk factor comorbidities.

Here I will take you through these two scenarios and the adaptations and considerations we need to employ when we see people with existing autoinflammatory disorders.

“This Isn’t A Problem” - You, The Reader

“If the person doesn’t meet a threshold for onward referral to Rheumatology then there is no problem - they present with tendon-related issues and we manage them” is what someone would say if they were naive to the ways auto-inflammatory conditions, particularly spondyloarthritis, affect tendons.

Let me spell out some problems:

Spondyloarthritis (particularly peripheral or PSpA) can be triggered by tendon load spikes just like normal tendinopathy.

Spondyloarthritis particularly affects high load tendon entheses such as the plantarfascia, Achilles, patella and lateral hip, just like normal tendinopathy. [1]

PSpA affecting the entheses of the high load tendons presents clinically almost indistinguishably from normal tendinopathy.

Tendon research almost exclusively removes people with spondyloarthritis from their cohorts to reduce confounding variables.

I could actually go further but I think I risk losing some of you to boredom. The point is made and these issues aren’t the crucial component of what I want to write about in this particular piece.

Managing Tendons On A Background Of Auto-Inflammatory Pathology

There are two main scenarios we need to consider and although they are similar in approach, the outcomes are slightly different so we will look at them in detail. These are:

* Person with DIAGNOSED spondyloarthritis.

* Person with inflammatory comorbidity that increases risk of DEVELOPING spondyloarthritis - namely psoriasis, ulcerative colitis, Crohn’s Disease, uveitis/iritis.

Hello! I’m Auntie Version and I am unbelievably excited to be MSKMag’s very own agony aunt. (We’re never going to be able to keep it secret so will immediately reveal that it’s me… Jo Turner 😉)

Q: Dear Auntie Version

How can I tell if I am suffering from imposter syndrome or if I am indeed not very good at something? Sometimes I worry that I’m failing at work when I don’t get good outcomes but then start going round in circles in my head. Could this just be imposter syndrome?

Yours, Imposter?

A: Dear Imposter?

Such a good question. The difference between imposter syndrome and objectively not being very good at something is whether your feelings and internal narrative marry objective evidence.

Imposter syndrome is classically characterised by feeling like a fraud (waiting to be found out) and not being able to accept praise, attributing any success either to luck, or the actions of others. This is despite evidence that you are in fact capable.

If you are genuinely not good at something, then objective evidence or constructive feedback might support your opinion of yourself.

You reference times when you don’t get good outcomes and it is probably tempting to conclude that this is supporting evidence for your internal feelings. Particularly in healthcare however, we need to give this context. Are you setting yourself a realistic bar for ‘good outcomes?’ Are you holding yourself to unachievable standards? How do your outcomes relate to those of direct peers, with similar levels of experience to you?

The problem with imposter syndrome is that it feeds perfectionism - it has us overworking and overwhelmed as we strive to achieve the impossible. Yes, we need to be accountable and work to maintain good standards of care, but imposter syndrome and perfectionism are often evidence of the balance having tipped in an unhelpful direction.

So when you look objectively at the evidence, does it genuinely support feelings that you are not good enough? If so, where can you seek good support to gain and improve your skills? If not, the support might be better directed towards helping you challenge those unhelpful thought patterns and behaviours.

Q: Dear Auntie Version,

How do I know how much I should specialise? I get bored being too general in my clinical work but worry that I will be less employable if I pick the wrong area!

Yours, Bored

A: Dear Bored,

My immediate (and flippant) response is that if you’re bored, you’re already less employable than someone who loves their job. But I also hear your concern about becoming so specialist that employers may see that you will only be able to see a small percentage of their client base.

There is a ‘Goldilocks’ option of specialising but retaining your generalist skills - I’ve heard this referred to as a ‘T’ shape career. You can treat most things that walk through the door, but you are the go-to person for your chosen specialism. That way, you get to spend a fair amount of time working on cases that really float your boat, but everyone knows you can treat other conditions.

I would say that specialism often increases rather than diminishes employability, particularly if you can pick something that is future proof. Look at what is going on in the wider world of MSK and outside. If you can offer something that helps an employer offer up to date services that are in-line with emerging evidence and peoples’ needs in the modern world, you’re going to be very popular.

And specialism needn’t be a trap. Nothing is forever. In a long career now, I’ve enjoyed many specialism chapters.

Q: Dear Auntie Version,

I see a lot of people talking about getting their health and fitness in order in the new year, but I feel like such a hypocrite. I’m not in a position to prioritise myself right now health-wise but still have to play the ‘Mr Motivator’ role. How can I walk the walk as well as talk the talk?

Yours, Mr Unmotivated

A: Dear Mr Unmotivated,

We all know that health and fitness regimes, even in someone with great insight and commitment, are subject to fluctuation or complete derailment - cos life happens. But we perhaps don’t talk about that enough as therapists. A colleague used a wonderful phrase on a clinic WhatsApp group recently. She said, “We all know each other, we know we are juggling and struggling at times but always have the best of intentions.” Admittedly this was clinician to clinician, but I think there is a level of being real we can find with our patients, without it being an overshare.

I’m a big fan of James Clear’s book ‘Atomic Habits’ and often quote it to patients. Whilst James advocates consistency as the key factor in habit formation, he also allows for variation in output and acceptance of ‘missed days.’ His point is that habits are not broken on the first missed day. Instead of thinking we’ve failed and all is lost, much better to have compassion for ourselves and commit to trying again tomorrow, or maybe even next season.

As for being Mr Motivator, fabulous though he was that was the 90s. Maybe Mr or Ms Relater is a more appropriate icon for our times.

Q: Dear Auntie Version,

I’m a physio working in an NHS clinic and the waiting times for appointments are getting me down. If I see someone today, I’m looking at 6 weeks before I can book them in for a follow-up appointment. It’s not working for them and it’s not working for me! How can I stay sane at work whilst doing my best for the patient?

Yours, Struggling

A: Dear Struggling,

I’m certainly not going to try and persuade you that having 6-weekly follow-ups as the only option for any condition counts as good care.

Sadly, it’s a situation many readers will recognise all too well. We know the problem is systemic, and hopefully most clinicians are not blaming themselves for it, but that doesn’t make it any easier when you’re the one sitting in front of an understandably frustrated, frightened or desperate patient.

So what can you do about it?

Some people channel their own frustration into activism. Are there avenues or organisations you can use to advocate for patients and push for change? Even small actions may help you reclaim some sense of agency.

Others decide to vote with their feet. If they can’t see any prospect of change, they choose to work in a different environment, maybe for an employer whose model better aligns with the care they want to provide, or they take the leap and set up their own service. Contrary to the belief of some, most people don’t go independent to chase a mythical high salary; they do it so they can practise in a way that feels fulfilling and sustainable.

I’m not suggesting that leaving the NHS is the answer and I recognise that for some this is an ethical no-no. It’s a tough situation and I don’t believe there are any easy solutions right now. You’re doing your best in circumstances that would challenge anyone. And it’s more important than ever to hold on to the parts of your life that exist outside of your work; interests, relationships and activities that remind you of your identity beyond the therapist trying hard in a struggling system.

Greetings and Happy New Year from my new role as Editor in Chief of MSKMag! Admittedly it looks a great deal like my previous role of Editor Adjacent to Chief of MSKMag, only with the added responsibility of penning this Editorial every month.

Of course with such great power comes great editorial responsibility (to borrow and slightly tweak one of our titles this month), and so if you have any feedback about MSKMag, or things you’d like to see more of, please do get in touch on [email protected].

My predecessor Jack Chew gave me this advice for coming up with trending MSK issues for the Editorial: get LinkedIn. Now forgive me for writing this in December whilst clinging to my Christmas jumper and mulled wine and putting LinkedIn firmly in my January to-do list. Tis not the season. By the time you read this though, look me up! I’ll be the new person without any friends.

The social media platform I’m found on mostly is Instagram and the trend stuck in my head and probably yours for the past several weeks comes with the soundtrack of Billy Joel’s lyrics from Piano Man ‘...and probably will be for life’ merging into a Fleetwood Mac song whilst a video montage plays, overlaid with the captions: ‘In your 20s…[a thing will present itself]. It is very important you [do/do not engage with/marry/get on board this thing]…’

Now who doesn’t love a self-reflective social media trend this time of year? You’ll have to sing the backing music yourself (if you’ve heard it once, you’ve heard it a thousand times) but here’s MSKMag’s January issue version:

In your early career, colleagues will tell you studying Ergonomics at Masters level will be boring. It is very important you do not listen to them. The result is Liz Prokopowicz’s article ‘The Human Factor’.

In your life, you will tell yourself that you fully intend to do all of the things including the home exercise programme and that new business venture. It is very important that you do not believe yourself until you’ve set up a framework to success. You can read about that framework in Nicola Graham’s ‘The Road to Failure is Paved with Good Intentions’.

In your clinic, you will see people with tendinopathy in whom you also really really suspect something else inflammatory is going on. It is very important you don’t ignore that instinct. Instead, read Jack March’s ‘Rheumatology and Tendons: Certainly No SpA Day’.

In treating hypermobility in your patients, you will start to notice certain trends among some of those who are neurodiverse. It is very important you allow these patients to feel seen. You can learn to do the same in Sue Julian’s article ‘Should we treat neurodivergent patients differently’.

In your practice you will be tempted to treat everyone you see using spinal manipulations ‘because chiropractic’. It is very important you listen to your grandad’s advice when this happens. Read about this advice and his own in Glenn Winslade’s ‘With Great Power Comes Great Chiropractic Responsibility’.

And, in your reading of MSKMag, you’ll occasionally disagree, often learn something new, and hopefully feel part of a bigger conversation. It is very important you keep joining in. Largely because it’s far less fun if I’m talking to myself. Here’s to the conversations we’ll spark in 2026.

Felicity Thow

Editor in Chief

In the UK, more clinicians are taking the plunge into MSK Point of Care Ultrasound (POCUS). The buzz is real!

Some are seeing it as the modern MSK clinic’s next essential tool, while others raise their eyebrows at how practical it truly is, asking whether it is just another expensive thing we can charge more for. Either way, it’s here, and growing FAST.

Our social feeds are showing packed-out courses, there are countless ads for devices, and videos and images being shared with a story whilst we squint at these images pretending to know what they are looking at.

So what is the real story? How do you learn POCUS? What should you keep your eye on?

We are going to go on a journey and look at it through three lenses:

* The beginner stepping into the unknown

* The educator guiding new learners

* And me, the industry insider who’s seen behind both the probe and the sales pitch.

So why are we talking about POCUS?

We can’t ignore it anymore. Diagnostic imaging, as a whole, is a staple part of our industry. Whether you are performing the scans or not, you will likely have referred someone for one at some point.

The wonderful aspect of POCUS is that it gives you real-time, dynamic imaging and elevates your diagnostic confidence. Rob Beaven, a Chiropractor just starting out in ultrasound, puts it like this: “My interest in exploring POCUS stems from a desire to enhance diagnostic accuracy, clinical reasoning, and patient communication.”

In a busy clinic, Rob sees how timely imaging can change the play: clarifying a working diagnosis, spotting red flags earlier, or simply helping patients visualise what we’re thinking. For him, ultrasound isn’t a replacement for skills, it’s a step up. “I see it as a way to strengthen my ability to form clear, evidence-based management plans and improve patient confidence in the process.”

Mike Bryant, a Physiotherapist, Sonographer and experienced educator, has watched the landscape dramatically change. He describes ultrasound as “a technical skill of probe manipulation, anatomical knowledge and pattern recognition,” - a skill that you master by doing, not watching.

From my standpoint in the industry, being a Sports Therapist BSc working within the device sales industry offers a rare insight into how both worlds operate. Understanding the clinical nuances of using diagnostic ultrasound, but also the business realities that clinics face when investing in new technology, helps me to separate the hype from the helpful.

The sector is developing quickly, with more models and variations coming onto the market seemingly every week and it is hard to keep track and hard to know who to trust.

The Reality Check

Spoiler alert: POCUS isn’t plug-and-play. I learned that very early on. Everything just looks the same at first. For beginners, the screen might as well be snow. Rob expects “a steep curve understanding anatomy from an ultrasound perspective,” and he knows his consultations might slow down while he gets comfortable.

Mike agrees, “The biggest misconception is that it’s going to be an easy process and that they’ll be proficient after a couple of courses.” He warns, “it takes time and dedication to grasp the probe skills and the detailed anatomical knowledge.”

His useful tip is simple: learn to scan normal anatomy before hunting for pathology.

From the supplier’s side I see how technology creates the illusion of ease. Handheld devices have made ultrasound look easy. You plug it into a tablet, start scanning, and it seems simple, but that simplicity can be misleading.

Back in January 2023 a UK qualitative study emphasised that POCUS implementation faces challenges including the need for proper training, education and quality assurance frameworks. [1]

A proposed framework for MSK POCUS by physiotherapists highlights the importance of integrated scope of practice, education and governance solutions. [2]

The takeaway: POCUS is a skill built with patience, repetition and humility. We all begin with fuzzy images; it’s the practice that sharpens the view.

Mentorship, guidance and the art of feedback

Here’s what truly matters: the people you surround yourself with, not just a flash fancy machine. Rob values training where there’s “a supportive, structured training environment.” Small groups, experienced tutors and plenty of low-pressure scanning opportunities.

Mike has seen and guided many clinicians through the educational pathway and has witnessed the evolution of courses. “Initially there were very few courses you could attend to get close supervision with experts,” he recalls. “Now, I try to keep sessions small and simple, with as much scanning time as possible.”

He designs his courses accordingly. “Learning in small sessions and going back to the same area and scanning it again really helps,” he says. He’s a fan of the online, two-minute video demos that “you can pause, replay, and practice at your own pace.”

But he also reminds learners not to get fixated on diagnosing the amazing tendon tear on day one. “The main challenge for most learners is getting regular supervision…and remembering to enjoy the process, not rushing to find pathology.”

Most clinicians I speak to care more about training and educational support than features and benefits. For me, good suppliers aren’t just selling a system, they should help you on your journey and make sure you get the most out of your investment.

In short: learning POCUS is like planting a garden. You need good soil, regular water and some time. The seeds don’t sprout overnight.

The Technology – a blessing or distraction?

Ultrasound tech has come a long way. What once filled a room now fits in a backpack, or even your back pocket! Mike observes that this shift has “enabled access to more MSK clinicians” and made the cost feasible for many more practices.

But don’t be fooled! From where I sit, yes accessibility has exploded - which is great - but aggressive marketing can make POCUS appear deceptively simple to learn and lead you into a false sense of security.

I’m asked all the time: “Do you have any demo units” or “What is your best price?” I appreciate some are on a budget, but if that is your main concern, hang fire on your POCUS journey. Your focus, above all else, should be on IMAGE QUALITY. If you’re new to POCUS, it’s safe to say you will be sh*t. Try and cut costs and you may get a sh*t machine. Meaning you will likely be double sh*t!

Simply, if the image isn’t clear, everything else becomes harder and wayyyyy more expensive!

But consider the other side, where Mike hits the nail on the head: “The best probe/device in the world cannot fix a bad operator. YOU must learn the craft before the tech.”

I also stress the responsibility to suppliers in this equation. For me, we are just as responsible for offering good care and services to patients. Of course, we have sales targets to meet, but I have seen this blind the reps to just getting a sale done. This short sightedness risks compromising both clinician confidence and patient safety as clients may not be getting the appropriate system for their needs, or the necessary support and device training.

So yes, join the tech revolution, but keep your brain switched on, this is not something to be rushed.

Time, patience, and realism

Here’s what I tell newcomers: the biggest investment isn’t money, it’s time. Rob gets this: “I know consistency will be key. Building a mental library of normal appearances takes scanning again and again.”

Mike has seen the drop-off: “People come back after six months and realise they’ve forgotten half of it…Keep the probe in your hand. Even five minutes a day matters.”

And from the business side: Clinicians are great at asking for training but considerably underestimate how much ongoing support they’ll need. Ultrasound is a long term investment. It isn’t like shockwave where you can just buy a machine and go, you are buying into a new, lifelong skill.

In practice this may mean you have to squeeze in scanning sessions between patients or grabbing your wife, husband, brother or mother to scan them!

Pro tip: if practicing on family members, keep them sweet and feed them with treats!

Even years down the line, it is good practice to revisit the basics regularly and stay humble when the images are muddy.

Ethics, confidence and the limits of POCUS

The governance and ethics side of things comes into focus with POCUS. Who can you scan? What can you scan? What can you say/not say? These are just some of the questions.

Having more access means more responsibility. Rob is mindful of this: “It’s about integrating findings meaningfully, not scanning for scanning’s sake.” And Mike agrees: “Clinicians want to use it on every patient, but sometimes less is more.” Ultrasound is a supplement, not the main event. POCUS comes after a subjective and objective assessment not before: There’s a fine line between being enthusiastic and being over-confident.

The technology is improving faster than the regulations, which means clinicians need to act responsibly. Governance will catch up for sure, but in the meantime, as mentioned earlier, surround yourself with good people to help guide you. And again, I stress the responsibility on those in the industry to know the regulations and not pass it off as the responsibility of the clinician. We are in this together.

Yes, you can do more with POCUS. But you must also know when to stop, refer and seek a second opinion.

Where POCUS is heading

Looking ahead, I’m optimistic. POCUS use in the UK is growing fast, especially in private MSK practice. AI features are already creeping in to help with image interpretation and workflow. But beware, these fancy features can be a blessing and a curse!

Remember Mike’s wise words: “You must learn the craft not the tech.”

Mike has seen how the community is growing as well and how it is bringing people together and inspiring growth. “Courses, workshops, peer groups, it’s a community now. People learn faster when they share.”

Rob describes his own path: “In the longer term, I see ultrasound becoming an integral part of my professional development and clinical identity… It allows me to offer more precise assessments and communicate findings visually with patients.”

In short: if you start this journey now, you’re getting in early. This isn’t just a shiny gadget; you are investing in yourself and your patients and gearing up to become a key part of how MSK clinics operate.

Key takeaways from the three of us

* Prioritise the fundamentals: Probe handling, anatomy, pattern recognition.

* Be kind to yourself: During the learning curve confidence will go up and down, and that’s ok.

* Commit to time and practice: Regular scanning and regular workshops beat one big weekend course.

* Have governance and a referral/second opinion pathway: POCUS doesn’t stand alone and you will need support.

* Buy cheap, buy twice. If you must, wait and save. Image quality is paramount – skimp on the system you skimp on the image. Don’t be double sh*t!

Final reflections

POCUS isn’t just about seeing what’s inside a joint or tendon. It’s about curiosity, patience and learning how to interpret shades of grey - both literally and figuratively. It’s a tool that rewards time and humility, where confidence grows quietly through repetition.

The first scans are often frustrating. Anatomy will look alien, the image drifts and changes, even the simplest probe angle feels like a riddle. But as our three perspectives show: the beginner gains understanding, the teacher guides progress, and the industry insider brings perspective.

At its best, POCUS doesn’t replace assessment or instinct, it sharpens them. It helps clinicians see what they’ve always known was there, only now with a bit more clarity, and a lot more grey.

References

* Akanuwe et al (2023), A UK qualitative study underscoring the need for proper POCUS training, supervision and governance frameworks pmc.ncbi.nlm.nih.gov.

* Smith et al (2023), A framework paper for MSK POCUS highlighting integrated scope of practice, education, competency, and governance solutions theultrasoundjournal.springeropen.comtheultrasoundjournal.springeropen.com.

Some quotes have been shortened or edited to fit the flow of this article. To see the full interview questions and answers, click here.

Box 1. An acute non-specific LBP patient with no ‘red flags’

A 28 year old woman has been suffering from her first episode of low back pain since lifting a 10kg box at work three weeks ago.

She says that she has been unable to do her job managing a hospital cafeteria for this time, and has not worked since her symptoms began. While anxious to return to work, she feels immobilised by the pain. Her work duties are varied, but generally involve very few physical tasks. She works full-time during the day and has no dependents at home.

In terms of activities, she says that she can sit for about 10 minutes and walk approximately 100 metres before she feels she has to stop due to her back pain. She reports that she is able to sleep through the night; however, her back is stiff in the morning and the stiffness lasts for about 10 minutes. There is no history of trauma or serious illness. The pain is limited to the low back area, without radiation.

On physical examination, there is marked limitation of anterior flexion and tenderness in the left paraspinal region. The neurological examination is normal, and her pain does not worsen in response to straight leg raising beyond 90 degrees. All other case history and physical examination findings are unremarkable and she has not previously been seen by any healthcare practitioner since her symptoms began.

Box 1 contains the text of a clinical scenario that was presented to physiotherapists, osteopaths, and chiropractors across the UK – first in 2003, and again in 2023 – as part of a study I recently published in BMC Musculoskeletal Disorders [1].

Across the two surveys, more than 3000 eligible clinicians took part: 1758 in 2003 (834 physiotherapists; 592 osteopaths; and 332 chiropractors) and 1388 in 2023 (511 physiotherapists; 621 osteopaths; and 255 chiropractors). In short, this was a big study that took up many months of my time over the last 20+ years.

Some background and insight

The 2003 survey was conducted as the baseline part of a randomised controlled trial that tested the effectiveness of mailed hard copies of a ‘LBP guideline awareness’ pamphlet package, designed by the late, great Gordon Waddell as part of a national media campaign in Scotland: printed clinical guidelines for LBP (RCGP 1999), along with nice glossy summary sheets for each back pain ‘stakeholder’ and a copy of the evidence-based booklet for patients, ‘The Back Book’ [2] (remember that?). This trial was the main study from my PhD at Keele University, supervised by Nadine Foster. The study was so big (and exhausting, given that I was doing the legwork on my own) that it added more than 2 years to my intended PhD completion time.

Let me give you some insight as to what these numbers meant for me as a PhD student back in 2003. All envelopes had to be stuffed by hand, all questionnaires were photocopied and stapled, and all letters and address labels had to be individually printed (albeit using mail merge, which occasionally crashed). The hand-stuffed envelopes had to be manually taken to and posted out from the university’s mail room. The first ‘wave’ of invitations were sent out using lists in a database file, either manually downloaded from professional registers, or provided as a spreadsheet. We had to manually exclude any clinician in Scotland, because of the ongoing Working Backs Scotland campaign.

We invited 3604 clinicians in that first wave of invitations. This meant that, for every single second spent preparing each posted envelope, on average, more than an hour of time was spent overall. Early envelopes were taking more than a minute to prepare; later ones around 30 seconds! Then, I had to track responses every day – and clear out the pigeon hole in the post room, which was usually overflowing – then for any clinician on our mailing list who didn’t respond within a fortnight, a second wave of invitations were sent in exactly the same way. Finally, for the 1758 baseline responders in 2003, half of these (allocated at random) were sent the pamphlet package by post, and then a further two waves of follow-up questionnaires were posted 6 months later. None of this included the time spent transferring the paper questionnaire data over to an electronic database, manually re-checking the accuracy of this transfer in 20% of all questionnaires from each stage, and then eventually analysing the data and writing it up.

I’m amazed that my then-girlfriend eventually became my now-wife, given the several near-all-nighters that had to be pulled at the physio school at Keele, with her helping me stuff envelopes and deliver these to the post room at all hours. The 2-hour daily round trips up and down the M6 between Birmingham and Keele didn’t help either, especially the one when I pranged my parent’s estate car that was full of envelope-stuffing materials.

Once my PhD was completed, I swore that I would never return to the topic again. I’d had enough; which partially explains why I didn’t write up and publish the inter-professional comparisons from 2003 alone (although I did present these at a few conferences). My research interests largely moved on to other aspects of pain science. Not to mention that posting questionnaires was expensive enough in 2003 (> £20,000 at the time) and has become more expensive since, not least due to exorbitant postage costs. However, by 2023, there were lots of options to send academic surveys by email, including my beloved REDCap – an excellent tool for researchers that I was already very familiar with – and during the COVID-19 lockdowns, I found myself unable to return to our university labs to collect in-person research data. Hence, the thought crossed my mind that an identical follow-up survey to the same three professional groups surveyed in 2003 might not only be valuable, but would also allow me to finally publish my now ‘out-of-date’ 2003 baseline data.

Work: the thing that you love or at least the thing that pays for the thing that you love.

It would be great if return to work planning was a simple A–B journey. The person is signed off, nature takes its course, they go back to work, and everything is fine. However, we know it isn’t like that.

The trouble is that most maps in musculoskeletal practice are drawn from a single source of information. We might be aware of the person’s job, but we don’t go very far into work-related outcomes in undergrad or post-grad training. What the person tells us is useful, yes. Complete, no.

For people in physically demanding outdoor or manual roles, missing landmarks on the landscape of their recovery can be the difference between a smooth return and a turnstile experience of work: repeated flare ups and a recovery journey that keeps stalling [2]. That threatens their livelihood, their identity, and their confidence in work.

Earlier this year I delivered a workshop at the ACPOHE (Association of Chartered Physiotherapists in Occupational Health and Ergonomics) study day in Cardiff: a sequential reveal of evidence bags I called Three Boxes. Wearing my dad’s old Ford Dagenham overalls and carrying a brick hod, I walked through three occupational health cases: Dave the digger, PC Peter Robson and ecologist Brooke Treadwell – with the aim of solving each return to work mystery.

The three boxes are simple:

* The story they tell us.

* The work they actually do.

* The bridge between them.

Box One: The story they tell us

The subjective history is our starting point. It offers symptoms, timelines, aggravating and easing factors, and early clues about why the problem has happened. Very often it’s because demand has exceeded capacity. Around this point, a fit note appears: ‘not fit for work’ or ‘fit for work with adjustments’ [3].

Critics of occupational health sometimes complain that the report ‘just parrots what the employee said’. People rarely describe the reality of their job in detail. It’s nearly always shorthand:

“Lifting patients.”“Carrying kit.”“Climbing ladders.”“Working with machinery.”

Each phrase compresses a complex movement landscape into something deceptively tidy. Rehabilitation based solely on that shorthand risks preparing people for a version of work that doesn’t exist outside the clinic. It can also keep people away from work that might actually help their recovery if the exposure is graded and dosed well.

The aim of the Three Boxes workshop was to show the necessity of seeing the full picture. That means asking more questions, going to the workplace where possible, and being nosy about tasks. A tape measure, force gauge and heart rate monitor tell me more than any job title.

Box Two: The work they actually do

Observing real, contextual function changes everything.