MSKMag OutLoud

Physio Matters
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MSKMag combines cutting edge clinical opinion with light hearted relief from the daily grind! Featuring insights from the finest minds in the MSK industry, MSKMag will keep you up to date with best practice evidence and the best topical memes. mskmag.substack.com

  1. 4d ago

    Who's Actually Keeping Physios in Check?

    If I think about my own appointments with physiotherapists as a patient recently, I’ve been told I need an MRI and I’ve been told I don’t. I’ve been told I need an injection, and the next one said I don’t. One says I need eight treatments, one says a couple and I’ll be fine. One says it’s my hamstring, the other says it’s my glutes. Same leg and still the same old me. And I think any profession, especially one that’s supposed to be science-based, should have some level of consistency. As a patient it’s actually quite worrying, and certainly not reassuring, to be handed polar opposite views by people with the same letters after their name. If I called three plumbers out to the same boiler and got three completely different diagnoses and three completely different bills, I’d assume at least two of them were having me on. I’m not sure why physio should be any different. Nobody’s keeping an eye on them It seems to me, as a patient, that no one’s really keeping physiotherapists in check, whether that’s in the NHS or privately. You need only look around at every other physiotherapy website offering cupping, or some new longevity treatment, or a new machine that promises to cure everything from back pain to ankle pain. You’ve got physiotherapists using electromagnetic waves with little or no evidence. You’ve got shockwave being offered for pretty much anything. And on that note, it also seems that physios are stepping outside what they’re individually competent in, and moving into areas they’re simply not qualified to move into. Nobody appears to be stopping them. So how am I supposed to choose one? How do I choose a good physio? It’s not because they have a degree. It’s not because they have an HCPC number, or they’re a CSP member, or a Physio First member. It’s not because they own a clinic, and it’s not because they’re a Band 5 or a Band 6. None of those things told me which of my physios was right about my hamstring. So on what basis can I choose one, and how do I know I’m going to get good treatment? Which brings me to the question of who should be overseeing what physios do and don’t do. I had a look through the HCPC’s hearings involving physios, and there are obviously (and quite rightly) cases to do with sexual impropriety and legalistic issues, and some to do with competence, but I couldn’t find one about cupping, or a laser, or telling someone they need ten treatments for their back when the physio down the road says it’s their hamstring. If a physio says you need cupping to help with your back pain, maybe they’re right. But if they’re not, who says so? Is there any link between the Advertising Standards Agency and any organisation within the world of physio? Because the advertising rules already exist, and from the websites I’ve been reading, nobody in physio seems to be using them. Is ongoing training really taking place, and if it is, is it effective? If it’s happening, I can’t see that it’s working. And here’s the real problem. The HCPC has failed. The CSP has failed. Physio First has failed. What do I mean by failed? Well, as far as I can see they are the main bodies in the industry; the ones with the widest reach. The HCPC is the regulator, so I’d expect it to be the one saying no to the vibrating massage balls and the cupping, and it isn’t. The CSP is the professional body, so I’d expect it to be the one making sure its members can read a research paper past the abstract, and it isn’t. Physio First represents private practice, so I’d expect it to play some role in advising clinics on taking the mystical stuff off their websites. It should be a science I’ve seen someone describe physiotherapy as an art form as if it’s like painting, where two very different things can be good at the same time and three things can all be true. But physiotherapy isn’t an art. It’s a science, or at least it should be, and I don’t think it is a science any longer, because science is about evidence - the best evidence we have available at this moment in time - and that’s not what I’m seeing. We’ve got older physiotherapists leaning completely on what they know, what they’ve seen, and anecdotal evidence. During my research I’ve seen physios broadly incapable of reading PubMed research beyond a headline and a conclusion. The same older physios are busy saying new graduates simply aren’t qualified to be anywhere near patients, and I fear that might apply to quite a number of them too. After all, we can’t even get physios to agree on whether manual therapy is a good thing or not. I’ve heard people say innovation is important, that there’s not always science behind innovative ideas, that you have to try things and have an open mind. As Carl Sagan is supposed to have said, having an open mind is a good thing, but not when it’s so open that your brain falls out. A new toy every fortnight One physio I’ve used seems to get a new piece of equipment every two weeks and sends out an email telling us how wonderful it is. Some measurement device or some healing device, something you jump on, something that rumbles and vibrates, new foam rollers, fancy boots you put on your legs, a handheld vibrator that buzzes you in some way, or a futuristic laser that looks like it belongs in Battlestar Galactica - all curing one ailment or another. Whilst the physio down the road says they don’t need any of those things and spends their time going through what’s actually wrong with me and what progress might look like. When there’s such vastly different advice out there, who do we believe? Is six a magic number? When it comes to the private physiotherapy world, from what I can see the overriding aim now is to make money and not to help patients. Every area is commercialised. I asked Google for the top ten clinics in my area, got a list and went to their websites. Four out of those ten sold packages of physiotherapy that I could buy there and then by clicking ‘book now’. Unless physiotherapists have somehow developed an incredible level of perception, or the ability to read minds, I don’t suppose they’d know whether I needed six sessions or ten without seeing me. So I had a look around at as many clinic websites as I could stand selling packages of three, six, ten and twenty sessions, and the overwhelming majority offer a package of six. So I wondered, is six a magic number? Is there some physiological reason that six is the number of sessions you need? Strangely, these clinics, for whom six seemed to be the default, all offered different appointment lengths. Some were 30 minutes, some 45, some 60. One offered 90, which I suppose means two of theirs equals six of someone else’s…or that nobody’s measuring anything. It made me wonder why one clinic needed a 60-minute initial assessment to figure out what was wrong with me, another needed 45, and another needed just 30. Are they twice as quick at diagnosing, or just half as thorough? Physiotherapy you can trust, apparently Then there are the websites. One clinic’s homepage tells me its physiotherapy is evidence-based and I can trust it. A few clicks later I’m reading about needles rebalancing something or other, the body’s natural healing being unlocked, and a happy chemical being released that will leave me feeling better in myself. And of course the old favourite, that it’s been used for centuries, which is great as historical context but isn’t exactly evidence that something works. Many things have been used for centuries. Tobacco smoke enemas, for one. Another site tells me its shockwave machine regenerates tissue and mends what’s damaged, and that it works for tendons and, in a phrase doing a lot of heavy lifting, various other muscle problems. And then there’s the clinic that’s obviously spent some money on a new toy. According to the website, this one speeds up healing, tells you when you’re ready to go back to sport and, my favourite, lets you get there without risking another injury along the way. What is this magical product? A measuring device. It … This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit mskmag.substack.com/subscribe

  2. 20h ago

    Osteoporotic Vertebral Fractures: are we doing enough?

    Vertebral fractures are one of the most common osteoporotic fractures, yet they are the one that we miss most often. Case study A 58-year-old woman presents with mid/lower back pain. She was lifting shopping bags out of her car boot and felt a twinge in her back. The pain progressively got worse over the next few days. It felt like a bad ‘back spasm’, similar to one she’d had before, and the pain wrapped around into her ribs. She has seen her GP, had one chiro and four physio sessions. Her pain was improving but she felt progress was too slow and her exercises were not helping. She had a lot of discomfort washing the dishes, sitting for prolonged periods and was unable to go for her usual long walk. Her pain was eased by lying down. At her first appointment I asked her what height she was and she said 5ft 5. I measured her and she was just over 5ft 3. Her imaging showed a vertebral fracture at T12 and evidence of an older fracture at T6. I see some version of this patient most weeks. If you work in MSK, you have almost certainly seen a similar case too. With the above history, would a vertebral fracture have been your working diagnosis? Would you have asked her height or measured her in clinic? The silent fracture Vertebral fractures are among the most common fragility fractures caused by osteoporosis, but they are also the least likely to be diagnosed. [1] One vertebral fracture occurs every 22 seconds worldwide! [2] Yet only 33% of vertebral fractures come to clinical attention, with nearly 70% going undiagnosed. [3]There are a few reasons vertebral fractures go underdiagnosed: * 65-75% of vertebral fractures have little to no symptoms. [4,5] They often show up years later as height loss or increased kyphosis, which gets put down to ‘old age’. * For symptomatic fractures many present like the typical non-specific back pain we treat every day and they have similar healing timeframes, with most of the acute pain resolving within the first 6-12 weeks. * Even when imaging does happen they are frequently missed. This is because sometimes they are not being looked for (referral letters have ‘low back pain’ written on them instead of ‘suspected vertebral fracture’), end plate changes can be subtle and easily missed, and even if they are noticed they are instead reported as ‘wedging, loss of height, or compression’. [6] Most of us could recite the red flags to screen for Cauda Equina Syndrome or spinal malignancy, but are we as confident when it comes to identifying signs of an osteoporotic vertebral fracture? Why one fracture matters A vertebral fracture is rarely a one-off event, it’s usually the beginning of a steady decline. Vertebral fractures can have a devastating impact on people’s lives. 1 in 5 women who have a vertebral fracture will have another one within a year. [7,8] Over 55% of older women with a hip fracture have evidence of a prior vertebral fracture. [9] Yet only 1 in 8 people with a hip fracture are taking osteoporosis medication at the time of the fracture. [10] If we improved our diagnosis of vertebral fractures and addressed it much earlier, could we prevent future hip fractures?We all know the statistic that up to 20% of people will die within one year following a hip fracture, but a less known fact is that up to 15% of men will die within one year following an osteoporotic vertebral fracture. [11] Medication can reduce the risk of vertebral fractures by 30-70%. [12,13] If you see someone with an osteoporotic vertebral fracture make sure they have been referred to their GP or a specialist for osteoporosis treatment. What should make you think vertebral fracture? Back pain is the most common presentation we see, and people with osteoporosis also get back pain (that is not a vertebral fracture). We can’t send every patient into a blind panic that they might have a fracture, so when should we consider that back pain might be something more? * Risk factors in clinical history. Has the person had a previous fragility fracture, taken corticosteroids for more than three months, or been diagnosed with rheumatoid arthritis? * Height loss. A historic height loss of over 4cm, or more than 2cm in a recorded period of time should prompt further assessment. Don’t just ask how tall people are - measure them in clinic. * Sudden back pain after minimal or no trauma. Lifting shopping, bending to the dishwasher, or coughing can all cause vertebral fractures in people with osteoporosis. * New or worsening kyphosis. Alongside assessing their spinal curve, measure wall-occiput and rib-pelvis distance. A wall-occiput distance of greater than 0 cm, or a rib-pelvis distance of less than two finger widths can be suggestive of a vertebral fracture. [14] * Pain that behaves differently. Pain from a vertebral fracture is often worse with standing, washing the dishes, sitting for long periods and is eased by lying flat on their back. Many people experience pain that wraps around their ribs like a vice grip. If someone isn’t responding as usual, and their symptoms don’t fit the typical pattern, consider their risk factors and whether it could be a vertebral fracture. * Stopping or missing a dose of Denosumab (Prolia). Stopping Denosumab medication is associated with rebound bone turnover, loss of bone mineral density (BMD) and an increased rate of vertebral fractures. A case study showed a cumulative 50 vertebral fractures between nine women after stopping Denosumab. [15] Stopping Denosumab should always be done alongside a specialist with a clear treatment and monitoring plan. If your patient is taking Denosumab make sure they haven’t missed a dose or have stopped taking it themselves. * Pregnancy and Lactation Associated Osteoporosis. PAO/PLO is uncommon, but if someone presents with severe back pain, especially if combined with height loss in pregnancy or while breastfeeding, consider vertebral fractures. Low bone mineral density is recognised as the most robust risk factor for fragility fractures, but 55-70% of fractures occur in people without an osteoporosis diagnosis on their DXA scan. [16] Don’t just rely on a DXA result to rule out a fracture - combine it with clinical history, risk factors, and fracture risk. Why do we panic when we know it’s a vertebral fracture? If we miss a vertebral fracture, or someone has a silent fracture, we rehab that patient like any other back pain patient. We load them, progress them, and get them back to their life. But this often changes once we hear vertebral fracture. People with osteoporosis are told to be careful - no bending, no twisting, no lifting. And this often creates a lot of fear. Yes, exercise modifications are important and needed. But fear of sustaining another fracture is the thing I hear most often in clinic. By the time people reach me, they have stopped going to the gym, significantly reduced their activity levels, stopped gardening or picking up their grandkids. They are deconditioned and therefore at a higher fall and fracture risk. But the fear doesn’t stop with patients, fear has crept into our own clinical practice and we are underloading the people who need to be loaded the most. How should we approach exercise? The Royal Osteoporosis Society’s consensus statement, Strong, Steady and Straight, advises that exercise is safe and beneficial for people with osteoporosis, including after a vertebral fracture [17]. It recommends progressive resistance training, balance training, exercises to support spinal posture, and impact at an appropriate level. In a study looking at women aged 65 and over, who had a vertebral fracture, a 12-week supervised resistance and balance programme improved their strength and balance, and reduced their fear of falling [18]. In the first 12 weeks after an acute fracture, the priority is pain management, and light activity as tolerated. It’s important to understand the location and fracture type so you can modify necessary movements. I educate people on ‘spine safe movements’ and how to modify day to day activities… This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit mskmag.substack.com/subscribe

  3. 4d ago

    Perimenopause and musculoskeletal health: what you need to know

    This is a free preview of a paid episode. To hear more, visit mskmag.substack.com If you’re a clinician or working with active women, you’ll probably recognise this familiar picture. A woman in her mid 40s seeks your help with joint or muscle pains which are taking much longer to resolve than they used to. She’s picking up injuries more often, and with her busy life and poor sleep patterns, she’s struggling to find a way forward. Caring responsibilities are overwhelming her, and she doesn’t have much time to herself to stay active, which is important to her to maintain her weight and her sanity. We know there’s usually a physiological basis to most injuries and that other factors influence them, particularly when hormones are fluctuating…but what impact does perimenopause really have? Menopause is marked clinically by the day which is twelve consecutive months without a period. Perimenopause is the phase preceding this, when women experience menstrual cycle irregularities and, quite often, symptoms due to changing ovarian function and fluctuating hormone levels (oestrogen, progesterone and testosterone). While the average age of menopause in the UK is 51 (globally 49), the normal range is 45-55 years, and some women experience premature menopause due to premature ovarian insufficiency, cancer treatments (radiotherapy, chemotherapy), hormone medications or surgery. Screening for this is essential as early menopause carries greater risks for bone and heart health. Time to reframe the conversation and giving everybody what they deserve Recent media interest and women’s health campaigns have prompted health care and exercise professionals and researchers to rethink menopause and the potentially significant impact it has on MSK systems alongside the cardiovascular, metabolic and nervous systems. Our patients - rightly - expect us to be empathetic and well informed. Women, clinicians and exercise professionals have been underserved. From hushed discussion around ‘the change’, limited research and training, to mixed messages around what really helps, it’s a difficult space. Some women report that valid concerns have been dismissed. Whilst it’s great that there’s greater awareness of perimenopause, it’s no wonder women are scrolling through Instagram, taking cold plunges and scrambling for supplements looking for a magic bullet. We deserve better. We have an enormous opportunity not just to help manage current problems but anticipate and potentially mitigate the effects of future detrimental processes in order to help women manage their own health and wellbeing.

  4. 4d ago

    Headache patients – dream or nightmare? Top tips from my headache student clinics

    This is a free preview of a paid episode. To hear more, visit mskmag.substack.com Are you ever uneasy when faced with a headache patient? Could you recognise potential trouble and respond appropriately? Headache disorders are commonly seen in our practices. Almost 10% of osteopathy appointments are solely for help with headaches and facial pain [1]. This statistic shocked me into headache education research myself [2,3], and ultimately into helping to create an evidence-based headache education programme for allied health professionals (EdACHe) Historically, we barely had any headache education in our undergraduate programme – did you? Most of us will experience a headache in our lifetime. About one in seven people live with migraine (increasing in women in their late 30s/early 40s). In those diagnosed with migraine, almost one in five have sought help from a physiotherapist. About 5% of us have more headache days than clear days [4]. These are known as chronic headaches. These disorders are associated with personal and societal burdens of debilitating pain and disability, damaged quality of life and unthinkable personal and societal financial cost [5]. We can legally put cervicogenic headache and migraine prevention on our websites, yet are we really ready for the forensic attention to detail demanded of us by our headache patients? Headache specialists do routinely refer their patients for physical intervention alongside pharmacological therapy, especially if neck pain with movement restriction is present. Physiotherapy is most used by neurologists for patients with cervicogenic headache (CgH/CeH), chronic migraine (CM) and chronic tension-type headache (CTTH). Evidence for the usefulness of physiotherapy combining manual therapy with exercise training and patient education abounds [6,7] but is not perfect. A whole bunch of tests exist to help diagnose cervicogenic headache, plus likely cervicogenic triggers and ‘drivers’ for migraine and tension-type headaches [8, 9]. It’s good to know that only four tests are most useful [10].

  5. 4d ago

    Everyone Thinks AI Can Do Anything. Just Not What They Do

    This is a free preview of a paid episode. To hear more, visit mskmag.substack.com It can write their marketing, answer their emails and probably do their accounts better than their accountant, but suggest AI might do some triage or follow-ups or (heaven forbid) some actual physiotherapy, and suddenly it’s dangerous and unproven and years away and patients will never go for it. I see a lot of false narratives at the moment and most of them are self-serving. You only have to spend five minutes on LinkedIn to see “AI can’t ever do this, AI can’t ever do that“ and there’s always the same old pushback: “Yeah but patients want humans; people don’t want online physio.“ “Didn’t you know my hands are magical?“ It was suggested to me that this article is probably a couple of years too early but 2026 is very different to 2006 or 2016. We aren’t in a position where an industry can sit back, fail to modernise, continue being two steps behind and expect to survive as has been the case in the past. Even forgetting AI for a moment, I probably chat with more clinic owners than just about anyone and speaking purely from a commercial standpoint, the successful clinics today are embracing change and have been for years, and the clinics that aren’t are being shown up - badly. I’ve often said, if you’re still operating today like you did five years ago, you’re falling behind. In 18 months you won’t have much of a business left. Why? Because AI changes everything; this time it’s not just a case of someone technically, strategically and commercially immature ending up at 60 owning a clinic they thought was their pension and realising it barely covers the cost of an all-inclusive holiday to the West Bank. This time, those clinic owners that don’t adapt simply won’t be around for much longer. “But Michael, you’re wrong, patients didn’t want online physio in Covid so they won’t want AI physio. People need the human touch. AI is just not something we need to worry about.”

  6. 4d ago

    The Art of Managing Uncertainty in Clinical Practice

    This is a free preview of a paid episode. To hear more, visit mskmag.substack.com As I write this, many are bracing themselves for the start of a new school year. A new year, new teachers, new schools for some, exams on the horizon for many. I’m sure many of you have had those conversations with your kids where we try to reassure them that everything will be ok; the truth is, of course, we don’t actually know that. We are trusting that they will find their way through, and we hope to give them some reassurance that we will be there to, metaphorically, if not literally, hold their hand as they make their way. I was struck by the similarity between my roles as a parent and as a clinician. As a non-interventional pain clinician, this is primarily about helping people make sense of their pain. There is a great deal of ‘handholding’ involved in this (I try not to actually hold my patients’ hands; it gets awkward). This is all about navigating an uncertain world, both in terms of understanding what has happened but, perhaps as importantly, what the future may hold. Do I know what their future holds? No, of course not, no more than I know what the future holds for my kids, but I can hope to prepare them for whatever comes. My last article was about the challenges facing FCPs/APs in the UK. Among the various challenges, diagnostic uncertainty came up again and again in the literature. MSK health conditions are among the most complex, multifactorial issues we see in medicine. Uncertainty is rife, not just in identifying the most applicable diagnosis (or diagnoses) but also around prognosis, therapeutics, risk management, and, especially for FCPs/APs, the boundaries in terms of scope of practice.

  7. 4d ago

    Forecast: Uncertain - Editorial - MSKMag Issue 35

    This is a free preview of a paid episode. To hear more, visit mskmag.substack.com In recent years I have become obsessed with the Northern Lights. This is good timing actually, because we have been in a peak of the approximately decade-long cycle of solar activity, meaning space weather is, for a time, madder than usual. In 2024, that led to a series of events whereby we paid for flights and trains to the Arctic Circle for the September, only to see the aurora in my actual back garden in the May. You might have seen that there was an explosion of solar activity again this mid-October - you might, as I did again, have even seen the resulting Northern Lights in your back garden. I have seen a lot of silly things in my west end of Newcastle suburb but a green haze across the street, strong enough to beat city light pollution, might just top the lot. As a planner, the best and worst thing about the Northern Lights is their uncertainty. You have to be prepared: for the weather on earth, for the weather in space, with your photography equipment, to find dark skies…and crucially (as anyone who has forked out an arm and a leg for a trip to Scandinavia will attest to), for disappointment. Sometimes you find yourself in the right place - with dark skies, a stable camera and even a professional photographer - but the solar activity fizzles out into nothing. Sometimes your aurora alert app is dinging non-stop…but you can’t see anything for blankets of cloud. And sometimes, the activity of the literal star aligns, your night vision is not ruined by your security light, and you get to see the show. You will have, I’m sure, felt the same way sometimes in clinical practice: we can prepare all we like, but we can’t control the conditions. The road to recovery for both patients and clinicians alike is riddled with uncertainty. We are constantly adapting to ground shifts, atmospheric changes, and forecasts that read ‘uncertain’ - but that we still need to form a plan for. Oh, and can you do all this on your feet within 30 minutes? The challenge is summed up brilliantly by our staff writer Giles Hazan’s article this month: ‘The Art of Managing Uncertainty in Clinical Practice’ where he puts the problem into words and then shares ideas of how we can best embrace and respond to uncertainty without trying to chuck it away like a hot Chicken McNugget, which cameos in the piece. Is there anything more uncertain than perimenopause? Are my symptoms caused by it? Who knows!! Certainly not my own poor GP… BUT fortunately we do have experts like Claire Callaghan writing on ‘Perimenopause and MSK Health’; essential reading for anyone treating women from their 30s and beyond. If there’s one thing Helena Bridge’s headache patients are certain of, it’s that they’ve got a brain tumour - but what tools do we have in our kit to rule out the serious pathology and help improve the lives of those living with headache? Helena’s article ‘Headache patients: dream or nightmare?’ is packed full of practical tips. When, as Jenni Dowley writes, vertebral fractures are among the most common fragility fractures caused by osteoporosis, but also the least likely to be diagnosed, it’s safe to say we need to reduce our uncertainty in diagnosing them and ensuring people receive the right follow up care for their bone health. She helps us do just that in ‘Osteoporotic Vertebral Fractures: are we doing enough?’ And finally, Michael Schumacher is certain that ‘Everyone thinks AI can do everything. Except what they do’ in a blunt and important analysis of how MSK roles might be threatened by AI and what we can do about it now. The future might be uncertain but we’re not helpless. We can’t control the space weather, but we can make sure we’re standing in the right place and armed with the right kit when the lights come on.

  8. Oct 26

    The Zebra Farm: When Anterior Knee Pain Isn’t Patellofemoral Pain

    With cases from James Noake In musculoskeletal medicine, we are trained to recognise patterns. Most of the time, the answer sits comfortably within the familiar: overload, strain, tendinopathy. But every so often, something doesn’t quite fit. The story is slightly off, the response to treatment unexpected, or the clinical picture just a little too inconsistent. This is where the ‘Zebra Farm’ comes in. Each time, we explore a trio of real-world cases as written up by Dr James Noake (Consultant in Musculoskeletal, Sport and Exercise Medicine) in his upcoming book ‘Real World Sports Medicine and Musculoskeletal Case Studies : Knee and Lower Leg’. The cases challenge diagnostic instinct; presentations that look routine on the surface but reveal something far less obvious underneath. These are not just rare conditions for rarity’s sake; they are reminders of the cognitive traps we all fall into: anchoring, pattern recognition bias, and premature closure. Because sometimes, when you hear hoofbeats, it isn’t a horse. This is the Zebra Farm. In musculoskeletal medicine, few diagnoses are more common than patellofemoral pain syndrome (PFPS). Anterior knee pain, stairs, squatting, sitting, running, jumping pain all form a pattern to clinicians. Most of the time, the diagnosis is correct. But, every so often, patients present with what appears to be classic PFPS, only for the real diagnosis to sit somewhere entirely different. Perhaps in connective tissue, instability, or an embryological remnant hidden within the joint itself. This is where the Zebra Farm comes in. Each time, we explore a trio of real-world cases as written up by Dr James Noake (Consultant in Musculoskeletal, Sport and Exercise Medicine) in his upcoming book Real World Sports Medicine and Musculoskeletal Case Studies: Knee and Lower Leg. These cases remind us that not all anterior knee pain is created equal, and that pattern recognition can sometimes become pattern misrecognition. Because sometimes when you hear hoofbeats, it isn’t a horse. This is the Zebra Farm. Case 1: The Patellofemoral Pain That Was Actually hEDS and POTS An ex-ice skater, now into weight training, presented with: * Bilateral anterior knee pain * Generalised fatigue * Postural dizziness * Occasional palpitations At first glance, the knee symptoms looked like entirely plausible patellofemoral pain syndrome in a young athletic individual. However, the clue wasn’t in the knees - it was in everything else. The patient described: * Light-headedness on standing * Fatigue disproportionate to activity * Palpitations * Generalised hypermobility Increasing the chance that this is a systems issue, rather than an isolated knee injury. Diagnosis: Hypermobile Ehlers-Danlos Syndrome (hEDS) with Postural Orthostatic Tachycardia Syndrome (POTS) The anterior knee pain was merely one manifestation of a broader connective tissue disorder. The patient required multidisciplinary assessment including cardiac evaluation and investigation for POTS, which is strongly associated with hypermobility and Ehlers-Danlos Syndrome. Why It Fooled Clinicians * The presenting complaint was knee pain * Many patients with hypermobility are highly active athletes or dancers * The autonomic symptoms may be volunteered only when specifically asked Key Sign ➡️ Anterior knee pain accompanied by fatigue, dizziness, palpitations or widespread musculoskeletal complaints should prompt consideration of a systemic cause. Clinical Pearl As performing arts Physiotherapist Liz Bayley notes in her accompanying reflection: “Dancers, gymnasts, circus artists, divers, and skaters occupy a space where artistry and athleticism are inseparable, and where hypermobility is not only common, but actively celebrated. In these populations, hypermobility spectrum disorders (HSDs) and Ehlers-Danlos Syndrome (EDS) appear with notable frequency. It is not difficult to understand why. Children who are naturally “bendy” find themselves in environments where those qualities are rewarded - praised for party tricks, admired for high kicks and deep backbends, selected for their aesthetically pleasing lines, their pliable feet, their effortless turnout. What begins as a biological variation becomes, over time, a professional asset. And yet, the demands placed on these bodies have evolved. Dance in 2026 is no longer defined solely by artistry; it is increasingly virtuosic and relentlessly athletic. Choreography now requires strength, power, stamina, coordination, and precision at the highest level. Hypermobility challenges the traditional biomedical model - for those working with dancers and aesthetic athletes, it also requires navigating the tension between performance demands and physiological reality. Ultimately, while hypermobility may complicate clinical pathways, it also offers an opportunity to practice with greater curiosity, compassion, and depth. Being flexible goes both ways.” Sometimes the Problem Isn’t Pain... It’s Instability The first case reminds us that anterior knee pain can be part of a multisystem disorder. The next case appears far more mechanical. But what looks like patellofemoral pain is actually the aftermath of a major instability event. Case 2: The Patellofemoral Pain That Was Actually a Patellar Dislocation [pg 144 - inc MRI and USS images] A tall, hypermobile woman in her twenties landed awkwardly from a jump for a ball. The mechanism: * Single-leg landing * Dynamic valgus collapse * Immediate severe pain * Inability to weight bear Initial Thoughts Many clinicians seeing the patient later in her recovery might simply encounter: * Anterior knee pain * Retropatellar discomfort * Effusion * Quadriceps inhibition * Apprehension during loading Which can be features of patellofemoral pain. The Role of Imaging MRI demonstrated: * Patellofemoral dislocation * Medial patellofemoral ligament (MPFL) tear * Large haemarthrosis * Relatively shallow trochlear groove Ultrasound additionally demonstrated acute MPFL avulsion injury at the medial patellar border. Diagnosis: Acute Patellofemoral Dislocation with MPFL Tear The patella had physically escaped the trochlear groove, damaging the primary soft-tissue restraint that prevents lateral translation and resulting in structural instability. Why It Fooled Clinicians * Patients may not appreciate that a dislocation actually occurred * The patella often spontaneously relocates * Later presentations may resemble standard anterior knee pain * Quadriceps inhibition is frequently attributed to PFPS Key Sign ➡️ A valgus landing mechanism with immediate swelling, severe pain and inability to weight bear should trigger suspicion of transient patellar dislocation. Extra Zebra? One particularly important pearl from this case: Approximately 50% of acute patellar dislocations may have an associated MCL injury - make sure to assess this too. Could it be the cartilage? The first case was systemic, the second, instability. The third teaches an equally important lesson: sometimes the patellofemoral joint hurts despite the cartilage being completely normal. Case 3: The ‘Chondral Injury’ That Was Actually Medial Plica Syndrome A female weightlifter presented with: * Functionally disabling anterior and medial knee pain * Both retro and suprapatellar pain * Heat and redness (no rheumatology risk factors) * Clicking and catching sensations * Difficulty squatting even with low load * Symptoms during deep snatch positions Many clinicians would immediately think: * Patellofemoral pain syndrome * Chondral injury * Early patellofemoral osteoarthritis …and the history certainly seemed to support it. Clinical Findings Examination demonstrated: * Positive ‘stutter’ test * Positive Clarke’s test * Medial parapatellar pouch tenderness * Low-grade effusion * Mechanical clicking symptoms So far, so cartilaginous. The Imaging MRI showed: * Pristine patellofemoral cartilage surfaces A combination of MRI and ultrasound demonstrated: * A large inflamed serpiginous medial plica * Mechanical impingement during knee movement * Dynamic reproduction of the patient’s clicking symptoms Diagnosis: Medial Plica Syndrome The culprit wasn’t damaged cartilage at all, it was an infla… This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit mskmag.substack.com/subscribe

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  • Creator
    Physio Matters
  • Years Active
    2024 - 2026
  • Episodes
    99
  • Rating
    Clean
  • Copyright
    © Physio Matters
  • Show Website
    MSKMag OutLoud