By Ashish Dev

“It makes me feel quite ‘stupid’ telling a patient about the diagnosis as it makes me feel like they are thinking ‘he doesn't know what's wrong’. And then especially if it is someone who is already fairly active, strong etc I often don't know what to do treatment wise as there is no obvious target.” - BCP member (practicing clinician)

Very few conditions confuse the hell out of patients and clinicians alike more than patellofemoral pain syndrome. Right from the source of symptoms, identifying the contributing factors, modifying, and managing load, designing a rehab plan to providing the patient with a timeline for getting better is all but murky to say the least. The aim of this two-part blog is to explore this condition and I hope by the time you are done reading this you will be able to tackle this condition better as a clinician and as a patient.

WHAT IS PATELLOFEMORAL PAIN ?

 Patellofemoral pain is a fancy way of saying “kneecap” pain. “Anterior knee pain” is an u...

Too often the question of diagnosis is split into a binary of “does it or does it not matter”. This creates a dichotomy & polarity between groups. Maybe the concept of granularity is a better perspective than a binary one.

Granularity, in it’s essence, looks at how much detail do we need to go into in a given situation.

 Let’s take back pain. Everyone would agree that obvious signs & symptoms of serious pathology should be investigated with less granularity required for onward referral. Further granularity maybe applied (such as imaging) further down the line by other HCPs.

Most I suspect would also agree that differentiating between more specific Dx’s would also be important & require granularity too. So being granular regarding neurogenic claudication & radicular pain is likely to be of benefit.

This would likely change the prognosis, explanation & treatment around the Dx, therefore giving the level of granularity a benefit for the patient. This might also alter further granulati...

Non specific lower back pain (NSLBP) is the most common MSK problem world-wide. It is also an often-misunderstood problem! This  will help to de mystify what NSLBP is & is not & hopefully provide positive information to pass on to those suffering with NSLBP

What is it? “pathoanatomical cause of the pain cannot be determined” - Maher

“For nearly all people presenting with low back pain, the SPECIFIC nociceptive source cannot be identified” - - Foster

“Presumed MSK origin of LBP. No tests available to specify SOURCE reliably” – Bardin

https://pubmed.ncbi.nlm.nih.gov/27745712/

https://pubmed.ncbi.nlm.nih.gov/28359011/



So NSLBP is actually a pretty broad label, even though it is one of exclusion NSLBP could be muscular, tendinous, ligamentous, joint related or discogenic & these cannot differentiated via clinical testing It could also be contributed to by many things across the BPS spectrum

Its not something specific! 1% is serious pathology 5-10% is specific, Radicular (nerve root), Rad...

Faraz Sethi – MSK Physiotherapist           

‘It’s only a twisted ankle; ice it, strap it, a few ibuprofen pills and you can play this weekend mate’

If any clinician denies using the catchphrase above at some point in their career, then you might as well stop reading now!

Our impact

Following on from my last blog, I wanted to discuss the assessment of an acute ankle sprain and question; if we as clinicians are doing all that we can for our patients. According to the ROAST consensus statement by Delahunt et al (2019), 40% of individuals develop chronic ankle instability within the first year after their first ankle sprain.

Even though I think it’s a well-rounded paper, unfortunately the limitation is that all nine assessment criteria are focused on the pathophysiological response to an ankle sprain. I believe the icing on the cake would have been a 10th assessment criteria involving  patients self-reported emotional status. Personal factors, such as self-efficacy, resilien...

Do you need surgery for a full ACL rupture?

Despite surgical repair of ruptured ACLs being an almost automatic certainty in almost all countries on almost everyone… there is growing evidence that many don’t need surgery!

The impressive KANON trial showed that 58% of all ACL ruptures in their study healed within 5 years without surgery!

https://bmjopensem.bmj.com/content/8/Suppl_1/A3.2

And this could be even higher with a post injury protocol currently under investigation in Australia called the Cross Bracing Method

https://burleighphysio.com.au/article/acl-cross-bracing-method/

But even if the ACL doesn’t heal, many can still recover and return to high levels of function with good rehab just as well as surgical repair!



But what about the risks of knee OA after an ACL injury! Surgery is often said to reduce this risk!

However there is currently no evidence that surgical repair reduces the rates of knee OA after ACL injury! In fact it may increase it!

https://journals.lww.com/cjsportsm...

Faraz Sethi – MSK Physiotherapist

Patient Perspectives

 ‘There is an inner voice of it reoccurring; the fear of having another episode prevents you from doing stuff, I don’t want to sound melodramatic, but there’s definitely a feeling of anxiety and low self confidence, I don’t feel good about myself or the world’

What the hell does the above statement have to do with an ankle sprain? Well, this is what I heard two weeks ago in clinical practice from a 34-year-old female, recreational netball player who had quite literally ‘had enough’ after no-one was able to validate her pain experience from the past 3 years. All she wanted was some empathy…not a diagnosis.

‘It was pointless going to A+E, waiting for six hours to be told by the junior doctor on call to rest it, ice it, no netball for four weeks’ she explained, as well as leaving with a bag full of medications and creams. Sound alarmingly familiar? Don’t worry. It’s pretty common practice and we have been in this predicament nu...

When a patient tells me they have read something in the newspaper about back pain my heart sinks and my left eye starts to involuntarily twitch as usually its some ill-informed garbage about a quick fix, or drivel about a miracle cure that I have to try and convince them is utter bull shit. But from this week there is hope that a patient has at last actually read something useful about their back pain in the media.

The Lancet published three very important papers about back pain. These papers authored by the worlds leading researchers highlight how back pain is a huge global burden affecting millions if not billions of people worldwide, and how it is getting worse despite advances in healthcare, medicine and surgery. Please go and read these papers here, they are freely accessible and well worth an hour of your time.

These articles highlight how back pain is often grossly mismanaged and over treated with many ineffective and dangerous treatments such as surgery, injections, and medic...

Who are we?

The Better Clinician Project or BCP for short, is an easily accessible online platform that delivers clinically applicable information in easily digestible bite sized chunks. Set up back in 2019 by Adam Meakins and Ben Cormack, two well known clinician’s on the international teaching scene, the BCP has grown into a vast resource of evidence based clinical education that can be accessed easily via your computer or our app anywhere and anytime.

 Our slogan is “By clinicians, for clinicians” and this guides how we design and deliver our content to make it applicable to you the clinician. It’s not about us, it's about YOU and we are growing into a healthy and interactive online community that is a safe space to ask questions, find information and post tricky cases. The BCP is for ALL clinicians. We have physio’s, osteo’s, chiro’s, trainers, massage therapists, sports therapists and even more. You name it, we got it. This brings a huge diversity to our community that we absolu...

Over the last 4 weeks, myself and Ben Cormack have been interviewing patients on the 'Better Clinician Project' to gain their insights and experiences of both healthcare and the clinicians working within it. I have found these discussions such an invaluable resource and have learnt so much from them all and I cannot urge you all enough to go watch them now here.