Imagine, if you will, a nagging knee pain. Not to the point of limiting daily activity, but certinly limiting sporting activity.

What is the first approach? And if that doesn’t work?

In general, you can imagine a ladder: Physical, Chemical, Surgical. This is not unlike Galen’s idea of lifestyle, (regimen) pharmaceutical (drugs) and surgical (I have moderised it slightly) which, if nothing else demostrates continuity of thought for a good 1500 years.

In the case of the knee pain, the first step is to either seek professional input to correct any functional imbalances, or work on them yourself. If it is more inflammatory, then pain managment and anti-inflammatories can assist, especially if you subsequently require suppport from a rheumatologist. Only when all other options have been attempted, then consider surgery.

Surgery is interesting conceptually. It does not fix anything. If fact, no form of medicine ever heals the body. It simply creates the space and capacity, by supporting homeostasis, to allow the body to fix itself. So a surgeon cannot fix your knee, they can simply aim to restore function and reduce pain, whether through arthroscopy or replacement. And for most, that is sufficent.

How do we fit into this picture? We offer 20 years of physical therapy and functional rehabilitation experience, including pre and post surgical, information and support.

There will be an optimum point of effectiveness. The sweet spot where the amount of effort invested produces the optimal return. Improvements continue with more effort invested, up to a certain point, after which you will break.

Of course, there is also a dose response and overload repair argument going on, but most of those are only relevant in athletic or persuits where physical performance is paramount.

This also, I realise, is the same for medication. Too little paracetamol is ineffective, too much leads to liver failure. Just right leads to resolution.

To identify your dose, first choose your objective. Then look at the input parameters, and define the ones you can control versus the ones you cannot. Read what previous people have found efficatious. Sit down and chat with an expert. Then apply, record, reflect, review. Consistency is key.

If you don’t have standards, you have nothing to measure yourself against.

Don’t fall into the common trap of comparing yourself to other people, that’s impossible as they keep moving.

Instead. Define what is the minimum you will accept for yourself and strive to exceed that.

It doesn’t matter where you get them from, spend time reflecting on each major domain: mental, physical, emotional (internal), relationships, work (external). These should reflect your internal values.

Then stick to them and seek help from those you respect at holding you accountable.

You may note that these are not goals, these are facts.

For example, if you feel that you should be able to perform at a specific standard physically, stick to it, or train until you can. If you believe that relationships are important, work at them. If you think certain internal or external behaviours are incongruent with other standards, change.

If you find you need professional help, seek it, with the goal of improving. Whether that is medical, psychological or career, choose your expert and invest in yourself.

You probably sit too much.

We all do. I’m sitting to write this, and the chances are I will sit for the majority of my day, even though I apparently cover 7000 steps on average.

So you might as well do it with awareness.

As you sit, draw you focus to two areas, your ischium (sitting bones) and the base of your throat /top of your chest.

Find the sit bones and balance your wait over them. Start by leaning all the way forward and feel that. Then lean back and feel that. Now find the mid point. This should be a neutral pelvic position.

Now put your fingers gently on the base of your throat. Allow it to open up, and allow it to float towards the ceiling. This should naturally bring your head and neck, as well as your thoracic spine into a better alignment.

Finally, shift between the two areas and breathe gently.

This awareness, this sense of centering, should help unwind tension during sitting.

Now move.

We all know, especially in these desk bound times, that our posture could be a lot better.

But how to improve it? The theory of head up, shoulders back, tummy in, is all well and good but is practically impossible to achieve and generally wrong.

Why? Because it forces you into compromise stacked on compromise, by not taking into consideration the actual elements that are holding you in place.

Too long sat down can lead to short hips and chest, which will not lengthen instantly and any immediate corrections won’t last.

The only way to address these issues is slowly and with initial expert help.

Instead of head up, allow your neck to lengthen. Instead of shoulders back, think about opening up the top of your chest (along the collar bones). As for your hips? Stand, move, groove, and check your pelvis balance (for another day).

What with the ongoing kerfuffle, and the remnant workload elsewhere, it seemed prudent to protect everyone and shut the doors for a while.

And now, the doors are reopening. Slowly, with prescreening, but we are back.

Another case presentation to learn from. These are not the thousands of boring MSK presentations we all treat, these are the ones that slip the net. All anonymised, with several details changed. As always, these are aimed at professinal clinicians, and are for learning and reflection. This one was not seen in my clinic, but was relayed as a presentation in another establishment.

A 55 year old man presents to his private MSK practitioner with leg pain and weakness. Its been getting worse for a few weeks, but he was putting off seeking advice as it wasn’t that bad. However, having tripped over the rug at home and being unable to walk long distance without pain, he is finally being sent in by his partner.

Presenting complaint

A one month history of lower back pain, insidious onset, non specific location, but across the lumbar spine. No radiation into the legs, but occasional electic sensations in the sciatic region bilaterally. Pain can be somewhat relieved by analgesia, and position, but can be up to 7-8 out of 10. He has now noticed some weakness in the right leg, with his toes catching occasionally on random objects.

Medical History

No cardiovascular history, smokes 10 hand rolled cigarettes a day but no respiratory issues, no GI issues, no GU issues, previous lower back pain,with a slipped disc 10 years previously. A recent swollen knee after walking the dogs on moorland in shorts, which was treated as an infection by the GP with oral antibiotics and analgesia. No bowel or bladder changes. No fatigue, no weight loss, no night sweats, some occasional fevers (described as sweaty moments), which he was putting down to the remnants of the joint infection. He is taking Ramipril for hypertension and Finasteride for benign prostatic hyperplasia, no diabetes.

Social History

Self employed landscape company manager, wife and teenaged children at home, no regular sporting activities but regular manual labour. Moderate diet, 40 units of alcohol per week (mainly beer) and elevated BMI (33).

Examination

Clinical: Nil of Note. MSK exam: Some restriction on foward flexion, pain in lumbar region on sidebending ipsilaterally. Neurological examination: Reduced reflexes on the right lower limb, some subjective sensory change L4-S1 right. Upper limb and cranial nerve examination nil of note.

Working diagnosis

Lumbar disc bulge leading to compression of the sciatic bundle.

Treatment

Conservative soft tissue treatment to relieve pain and spasm, no manipulations used and pain managment techniques suggested. Patient booked for review 1 week.

Follow up

The patient presented the next week with worse pain and increased neurological symptoms. Examination indicated that there was now sensory change in the right L3 dermatome as well as L4-S1, with increasing weakness in the right foot. He also reported some constipation, which he put down to the use of codeine for pain management as per his GP advice. He also commented that he had had a couple more of the hot flushes, especially at night. The working diagnosis was still thought to be discal, if worsening slightly. Treatment was attempted, but no positional relief was found. The patient was safety netted and booked for a teleconsultation in a few days.

On telephoning, the patient reported continued worsening of the symptoms and increased fever. He also reported some hesitancy in urination. At this point he was advised to attend the emergency department at his local hospital.

On arrival at A&E, he was streamed by the triage nurse to the minor injuies team as this was seen at a lower back MSK presentation. However, his NEWs was found to be 4 due to elevated temperature, elevated respiration rate and tachycardia. With this in mind, he was moved to majors. Fortunately the reviewing medic was switched on and persuaded radiology to do an MRI of the lumbar spine, which revealed an epidural abcess in the lumbar spine. This was initially managed using IV antibiotics before surgical decompression of the corda equina and drianage of the abcess.

The underlying cause? Staphylococcus aureus infection from a number of blackthorn scratches on the moors that had led to the infective arthritis of the knee, which had subsequently migrated to the spine.

He recovered well, although will always be left with a foot drop and some bladder urgency due to nerve damage.

Learning points

1. Could this have been spotted earlier? The only significant points of note was the previous septic arthritis, and the occasional fevers. Most of us sensibly hear hooves and think horses. It would take a switched on practitioner to spot this one and even then, they would need the patient to persuade a busy emergency department to make an imaging request.
2. The practitioner made the correct choice to not continue treatment rather than just carry on. In my opinion, if the treatment is nt providing benefit or improvement, you need to reflect and reconsider the presentation. It may be the patient continuing to do something provocative or it could be you’ve missed something.
3. A full and thorough history is vital, and should be reviewed. The clue that of underlying infection was present was in the inconsistent fevers.
4. Blackthorn scratches in many locations do cause infection, but most often present with cellulitis or local septic arthritis, it is extraordinarily rare to move through the bloodstream like this.
5. This is unusual but we still need to hold a diagnostic seive in mind when considering presentations: VITAMIN C DEF is one but there are many others: Vascular, Infective, Trauma, Autoimmune, Metabolic, Iatrogenic, Neoplastic, Congenital, Degenerative, Endocrine, Functional. Some can be immediately rejected but at least they have been considered.

This post is aimed at professional practitioners. This is not for diagnosis, and is for informational purposes only. This was a real case , but has been anonymised for the retelling.

The idea of these is to reflect on what went well, what could have been done better and ultimately, how to improve practice.

Context – Pre Covid, so no prior teleconsultation.

A 72 year old female presented to the clinic with lower back pain. This had been present for a few months, on and off, but had got worse when she was pushing a chest of drawers across a room to clean behind it. Otherwise fit and well, she lived alone with 2 cats. A case history was taken, as well as general medical history.

The presenting complaint, a low back ache, had started some time ago, which she put down to the natural processes of aging and, as it relieved with over the counter analgesia, had not sought further advice. When pushing the furniture, she felt something “go” and as it hadn’t resolved with rest and painkillers, she sought help. It rated 8 out of 10 on a pain scale, easing to 4-5 out of 10 with certain positions but was not improving.

Her BMI was within healthy range, she had no preganacies, no smoking history, moderate alcohol intake and was active in the local community.

Her medical history was significant only for a well controlled haematological presentation (essential thrombocythemia – ET) for which she was regularly reviewed by the local hospital. Her only medication was hydroxycarbamide for this, and over the counter nutritional supplements from the health food store. Family history was of a sister who was being investigated for bowel polyps, a father who died of leukemia age 80 and a mother who passed away with a stroke.

Red flags (fatigue, weight loss, night sweats, unremiting pain, fevers, respiratory changes, unexpailned bruising, bowel and bladder changes) were negative, as were the 6 domains (cardiovascular, respiratory, gynaecological / urinary tract, gastrointestinal, musculoskeletal, and neurological). She noted that she had had a few episodes of loose stool, which were ongoing and darker than usual.

Examination indicated a restricted left sacroilliac joint, with point tenderness over this area and no other significant findings. There were no clinical findings of note.

A relieving position was found on the couch, where compression of the sacrum provided temporary relief.

However, on refection it was not possible to create a satisfying working diagnosis and to isolate the pain to a purely musculoskeletal cause, especially given the bowel changes. As such, I referred her back to her GP with a note, and without fee or intervention. (I will not charge if I do not treat due to medical concerns).

The rest of this case is from third parties, as the lady did not present again.

After a teleconsultation, the GP referred the patient to the emergency same day care unit at her local hospital. Here, blood tests indicated that her platelet count was very low and she was admitted for further investigation and medical management. She sadly passed away a week later, as her ET had flipped to an acute form of leukemia.

Lessons learned:

1. The presentation looked like a lower back pain, with no significant clues that there was an underlying pathology. In this case, I suspect that it was acute back pain, on top of pathological changes from the medical presentation.
2. I need to learn more about common medications, and be willing to check the BNF if I am unsure.
3. This was only caught as I have a strict set of protocols and am naturally cautious. If she had been a more assertive character, or I was tired, I may have missed certain elements and may have treated inappropriatley.

If you’re not making progress, flip the question.

Rather than figuring out how to get somewhere, change perspective and look at what’s holding you back.

Experience and research suggests that it will almost certainly be in one of five major domains.

• Knowledge / skills
• Time
• Support
• Mindset
• Stress

If you don’t have the knowledge, seek expert help (not an internet expert!) start learning and practicing.

Time? Drop something else.

Support? Ask for help, negotiate. Get a good team around you. And if they are still not on board the program, then perhaps you can consider whether they have your best interests at heart.

Mindset? This is subset on its own, covering positivity, discipline and motivation. Without positivity, you’re already doubting yourself, motivation will provide the why and discipline will get you over the days of low motivation.

As for stress? The body can only deal with so much stress and no matter how hard you push, the self discipline you impose or the importance of your goal, if you overload you will break. If you realise you are stressed and the bucket overflows, deal with that first rather than throwing in yet another rock.

Now, I accept that, on reflection, location is also a barrier, but argue that that can be mitigated with support and knowledge. You may not be able to access a gym, but a rug shaped space in a room can be sufficient for a start.

Focus on the primary domain (there will be crossovers and combinations) and onwards.

We are experts in mobility, physical therapies and integrated medicine. We have significant expertise in nutrition, multisport coaching and goal attainment. We have years of education, qualifications and experience. We know when to say no, as well as yes. We are not ‘gram influencers, instant social media experts or personal trainers. Pick your poison.

Due to the ongoing kerfuffle and workload elsewhere, the clinic will not be open for patients until the second of March.

We will be following NHS Infection control and statutory guidance beyond that point to ensure the safety of all concerned, so further updates will be posted as and when.