A few years ago, if you asked most clinicians what they wanted AI to do, ‘write my notes’ would have been pretty high on the list. Which is fair enough; nobody became a physiotherapist because they had a deep passion for clinical documentation.

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

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

The invisible workload of good care

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

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

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

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

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

We started with clinician-centred AI

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

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

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

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

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

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

The gap between knowing and doing

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

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

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

What does patient-centred AI actually look like?

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

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

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

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

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

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

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

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

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

What about when the patient disappears?

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

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

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

What if the software already understood the plan?

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

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

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

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

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

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

Horizontal AI versus vertical AI

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

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

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

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

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

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

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

What happens in the real world?

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

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

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

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

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

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

Perhaps we asked AI the wrong question

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

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

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

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

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

References

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

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

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

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

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

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

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

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

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

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

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

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

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

The Missing Town Square

A 12-year-old soccer player lands in knee flexion from a jump and develops sudden left-sided anterior knee pain. He cannot continue playing, is reluctant to flex the knee, and describes giving way on weight-bearing. He cannot perform a straight leg raise (SLR) or adequately contract quadriceps because of pain and has an effusion. Plain radiographs in the emergency department are reported normal, and he is discharged without walking aids or follow-up.

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

Why adult reasoning isn’t enough here

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

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

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

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

Are all 12-year-olds the same?

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

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

Diagnosis, Uncertainty, and the Limits of Orthopaedic Testing

2014

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

* Test accuracy is heavily clinician-dependent

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

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

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

2026

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

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

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

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

* Symptom behaviour

* Load tolerance

* Movement quality

* Functional limitation

rather than strict structural identification.

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

Current nuance

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

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

Tendon structure, function and adaptation

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

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

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

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

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

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

Tendinopathy: capacity, symptoms and pathology

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

Happy New Football Season to all who celebrate!

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The unstable scapula: a clinical re-frame

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

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

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

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

Hello! I’m Auntie Version (aka Jo Turner) and I am unbelievably excited to be MSKMag’s very own agony aunt.

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

Dear Auntie Version,

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

Sweaty Betty

Hi Sweaty Betty,

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

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

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

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

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

Auntie Version

Dear Auntie Version,

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

To Leave or Not to Leave?

Dear TLONTL,

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

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

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

Auntie Version

Dear Auntie Version,

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

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

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

How can I claw back some pride??

Jack Chew

Anon

Hello Anon.

Firstly, commiserations on your miserable performance.

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

Or are they? (uninformed)

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

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

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

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

Auntie Version