MSKMag OutLoud

Shockwave Therapy: A Love-Hate Story, and Everything In Between

This is a free preview of a paid episode. To hear more, visit mskmag.substack.com [https://mskmag.substack.com?utm_medium=podcast&utm_campaign=CTA_7] Shockwave therapy… I was surprised to hear it hadn’t been covered in MSKMag. So, when the opportunity came to write an article on it, I jumped at the chance. Those who know me will know I work for Physiquipe, a company who sells shockwave therapy devices. And for those who don’t know me, now you know I work for a company who sells shockwave devices! Despite my ‘commercial interest’, I’m an enthusiastic Sports Therapist who is passionate about shockwave therapy, but I am no evangelist (Jack Chew can verify). I truly believe it has its place, and if you’ve invested in this technology to better serve your patients, then kudos to you. I’ll assume most of you have encountered shockwave at some point, and you are aware of radial and focused shockwaves and their differences. If not, I implore you to have a read up as this article is not going to cover this, nor be the RCT regurgitation we see at every conference. I want to share something a little different: an honest look at what the shockwave world looks like from where I’m standing. And perhaps offer something useful for those still trying to make sense of it. There are many sides to this story, so let’s start with…

Physios are nice...and it's killing our profession

This is a free preview of a paid episode. To hear more, visit mskmag.substack.com [https://mskmag.substack.com?utm_medium=podcast&utm_campaign=CTA_7] Putting the finishing touches to this article, I skim back over the Writer’s Guide. It encourages me to write boldly and to not be too afraid to offend because… “you’ll be surprised how polite professional challenges are in our industry.” We are a caring bunch…and this is exactly the problem. Three years into my Physiotherapy career I rotated onto an orthopaedic ward and attended the morning trauma round. It’s a cramped office in a quiet and worn out section of the hospital. X-ray after X-ray flashes up on a large projector at the front of the room and one-by-one the consultants discuss their patients and what intricate method of carpentry they will be using. It starts smoothly; there are not many questions and this silence appears to be taken as consent to continue by those presenting. But Case 5 is different. Heads look up, Candy Crush is paused and the temperature of the room heats up. Multiple consultants pile in, questioning and attacking the proposed management. The presenter fights back… “I’ve managed dozens like this non-operatively!” “Look at the posterior fragment!! If this was your ankle, you’d fix it.” “The displacement is minimal.” “That’s nonsense! If this displaces further, that’s on us.” “And if it gets infected, that’s also on us!” I catch the eye of an OT and we share a nervous wince. The ‘nonsense’ comment seemed to cross a line. However, a few minutes later the meeting ends and instead of any awkwardness or anger, the same consultants who were tearing chunks out of each other minutes before leave together, talking about the Six Nations score at the weekend. Not one hard feeling between them… and I thought it was brilliant. Only weeks before I had been on an MSK Outpatient rotation where one of our *cough* more experienced *cough* Band 8As had been training for a half marathon and developed some hamstring pain. They were complaining during team training about how they’d tried everything to resolve it without avail. ‘EVERYTHING’ seemed to be that they had been doing frictions on their hamstring… But instead of professional disagreement or debate, there was just meek silence from us all. Just a few quiet comments later in private. Some even played along at the time, humouring the outdated practice. We are a caring bunch… but we can be incredibly fragile.

The Corporate Athlete

This is a free preview of a paid episode. To hear more, visit mskmag.substack.com [https://mskmag.substack.com?utm_medium=podcast&utm_campaign=CTA_7] If you mention the words ‘elite performance’, most people will think of sport, but I think of the corporate sector. Both elite groups have talent, skill and can perform at maximum capacity. Both environments are highly competitive, deadline driven and with high stakes. But only the elite sportsperson works at the extreme of physical capability, developing problems when even their highly trained system cannot tolerate the physical demand placed upon it. Contrast this with the corporate athlete, whose mental load is so high it dramatically reduces their ability to tolerate minor or more moderate physical loads. Where these two groups experience their symptoms may be similar, and examination may come to the same diagnostic conclusion. But, given the differences in the reason for onset, their successful management, including return to activity and prevention of recurrence, will look very different. In the office the elite capability is mental and the load is continuous. To survive in this environment, you need to satisfy the demand for elite performance over long hours, day after day, month after month, year after year. Those who thrive enjoy the challenge and the competition, loving the work, the camaraderie, and of course their success. But many work at their limit of tolerance; constantly, and often unpredictably, permanently on call, and perilously close to burnout. Driven and academically gifted, these workers excel at school and elite universities. They are then thrown into the rigour of postgraduate training and onboarding programmes which instantly involve long hours, high stress, high accountability, tight deadlines and the constant, urgent need for accuracy. When junior, this group often fly the plane whilst building it, and when senior, manage a team and the clients’ expectations whilst managing caring responsibilities (in both directions) and experiencing an age- or menopause-related drop in physiological resilience. Everyone they work with (and compete with) was best in class too: they need to maximise their performance and keep it there to keep their job and stay in the game. They may work flat out for several months, only pausing for breath between cases, deals or deadlines. Many routinely work late into the evening, during the weekends and on holiday. They can be permanently on call. Additionally, with many companies going global, the traditional working day has been turned on its head: for some this can mean waking up for Asia, not logging off until America and working 80-120 hours per week. [1] For others the sheer volume of the work can result in their employer paying for ‘roundabout’ taxis: a ride home with the taxi waiting so they can shower and change and come straight back to the office. [2] Even away from these extremes, in these types of occupation a working week of 70-75 hours is very much the norm. [3,4] Welcome to my working world.

Do adolescents get rotator cuff tendinopathy?

This is a free preview of a paid episode. To hear more, visit mskmag.substack.com [https://mskmag.substack.com?utm_medium=podcast&utm_campaign=CTA_7] The short answer is no - at least not in the way the term is typically applied in adult populations. Rotator cuff pathology is uncommon in paediatric shoulders, particularly in the absence of trauma [1]. While partial or full-thickness tears can occur, these are usually associated with acute injury, avulsion, or instability events. In contrast, the most frequent causes of shoulder pain in adolescents are physeal stress injuries and glenohumeral instability with associated labral pathology [1,2]. These distinctions reflect fundamental differences between paediatric and adult shoulders in terms of anatomy, pathology, and clinical presentations. A failure to recognise these differences risks misdiagnosis and inappropriate management, potentially leading to long-term consequences for shoulder function and athletic development. Accurate clinical reasoning in this population therefore requires consideration of anatomical development, ossification timing, maturation status, and paediatric-specific pathology. From cartilage to bone At birth, the skeleton is largely cartilaginous, enabling longitudinal growth. Through the process of ossification, cartilage is progressively replaced by bone, with skeletal maturity around the shoulder not reached until the mid-to-late twenties [3]. Until then, shoulder injury is more likely to be to the immature bone, whereas in skeletally mature adults, the bone is stronger than the soft tissues, so injury is more likely to the tendon or ligamentous structures. The shoulder is particularly complex in its developmental anatomy. The humeral head initially forms from three secondary ossification centres, including the greater and lesser tuberosities, which unite around the age of 4-6 in boys, and up to two years earlier in girls. The diaphysis (humeral shaft) and the epiphysis (humeral head) are separated by the physis which is comprised of a series of layers packed with chondrocytes and osteoblasts to enable longitudinal growth. The humeral head does not ossify with the humeral shaft until around the age of 14-18 and until then the proximal humeral physis is vulnerable to injury.

Who is Responsible?

I look around the waiting room. There’s an average BMI of about 40. I observe oedematous ankles and a variety of walking aids (some flowery so you know they’re not a temporary feature). I can almost smell the inflammatory soup. A young person sits glued to an iPad, headphones shielding them from the world. No doubt an ADHD diagnosis inbound. The health of the nation has changed, and not for the better. And I wonder, when did MSK care become less about sprained ankles and bad backs, and more about metabolic disease and mental health? But who is responsible for this decline? Scanning the room, my instinct is to lay responsibility at the door of the individual. The media will have us believe that our beloved health service is failing the nation but is it in fact the nation who is failing the health service? As someone who works hard to maintain a healthy, balanced lifestyle, I am of the belief that I need to be accountable for my own health. Not every condition is avoidable or preventable, but I feel that I need to at least do my bit. I’m no teetotal, clean-living vegan, but nor am I held together with statins and gabapentin. Don’t misunderstand me, as a healthcare professional, of course I believe that access to healthcare is important, but with such a high incidence of people living in poor health (89% of deaths in the UK are attributed to non-communicable diseases) surely, we all need to step up and do our bit? I am not, however, optimistic. ‘The Spectrum’, overwhelm, body positivity, and food noise are just some of the reasons one can choose to justify an external locus of control. But these are avoidance tactics. Avoidance of the difficult, the uncomfortable. Avoidance of Responsibility. I hear the food noise; I can hear the packet of biscuits seductively calling me but I’m not a labrador and am able to exercise a degree of self control. Is it always easy? No. The same way that curling up on the sofa might feel more appealing than heading out for a run. We all have choices, and we are all capable of autonomous thought (even if these days we seem not to exercise that particular skill). Before judgement completely takes over however, and I am able to reach the lofty heights of the moral high ground, I am pulled back by the sight of a physiotherapist escorting a patient with magnetic knees back to the waiting room (if you aren’t familiar with magnetic knees, they are the kind that due to years of deconditioning and lack of proper use, are drawn to each other as if the medial femoral condyles are polar opposites!). The patient has just undergone a steroid injection and the physio gives them some instructions about a couple of days rest, then hands them a sheet of exercises. Patient and physio part company like a couple of England football fans*; both hopeful for success, both expecting disappointment. And my judgement shifts, from the patient to the physio. Like a warning light on the dashboard of your car, the focus here seems to be on turning the light off, rather than addressing what triggered the alert in the first place. Corticosteroid and a few clam shells aren’t going to address years of deconditioning, poor diet and social isolation. And I ask myself again, who is responsible? While I still stand by the importance of taking care of our own health, we can only do so if we are educated - if we understand what is going on in our bodies and are aware of our choices. With so much access to information and misinformation it can be a minefield for an individual to navigate. But I see MSK services stuck in the past. Clinicians still treating knees and backs in isolation and failing to treat people. Failing to acknowledge the complexity, and failing to have honest, albeit difficult, conversations. And clinicians have their own set of excuses. Their own reasons for absolving responsibility. No time; out of scope; it only says ‘knee’ on the referral. The system is s**t. Now I do agree that time pressures in MSK services are a limiting factor, and services need a redesign, and I hear clinicians complain, but I don’t see them upskilling to meet this new demographic head on. If time is such a precious commodity, why are we wasting it trying to identify dysfunction rather than discussing dysregulation., Why are we not prioritising conversations about the impact of weight, stress, hormones and sleep on pain and MSK health? I see a dramatically changed patient population, but MSK clinicians failing to acknowledge or keep pace with these changes. Many pay lip service to a biopsychosocial model, remaining entrenched in a ‘lets fix it’ biomedical model, not because they are lazy or ignorant, but because they lack the skills to challenge the status quo in a meaningful way. Why should patients change, if clinicians are not prepared to do so? I do worry that if MSK professionals fail to upskill to meet the shifting demands of health, if they are not willing to take on the responsibility of helping patients to navigate these health challenges, they will become obsolete. But I digress, as this piece is about the responsibility of health and not a debate about the future of MSK services. That is perhaps for another day. I scan the room once again, and wonder if I am being unfair to my MSK colleagues. Why should they take on the nation’s ills, simply because pain is the thing that demands most attention? Shouldn’t the proverbial buck stop with primary care? As the first and most consistent point of healthcare for most patients, they are best placed to provide holistic, ongoing support. Patients might spend several years, sometimes a lifetime, with the same GP practice. Responsibility should surely start here as the best place to effect sustainable change?? True that GP practices are under pressure, but maybe this is being perpetuated by referring away to specialist services with the promise of a solution, only to find patients boomerang back when the problem persists. There is some good news! There is a small, but growing number of GPs who are upskilling in the field of lifestyle medicine. Finally, some responsibility! But just as I begin to fantasise about a world in which all GPs are as skilled in promoting health as they are at treating illness, I look round the waiting room once more. Lifestyle medicine is still the exception, and far from the norm. Once again, I think about responsibility. What caused this epidemic in the first place? Several people sit scrolling on phones, someone opens a packet of crisps, another an energy drink…I’m not sure that the thumb movement involved in scrolling through Instagram requires that level of sugar and caffeine! My heart sinks with the realisation that what we are facing isn’t just about helping people make healthier choices. This is full scale addiction. Smart phones keep our sympathetic nervous system fired up, keeping us in fight or flight for sustained periods. And we now know these things aren’t addictive by default, they were designed that way. Add this to food-like substances, developed to leave you craving more, failing to nourish, creating inflammation and a heightened sense of threat in our nervous systems. The nation needs a detox! So, who is responsible now? The tech companies? Food conglomerates? The Government? Are we fighting a losing battle here, or does this bring us back to the beginning and individual responsibility? The addict can blame their dealer, but it’s supply and demand. We want life to be easy, convenient, and comfortable, but the easy choices in the short term don’t always serve us well in the long term. The important thing to realise is that there is choice. Clinicians can help a person on their health journey, but change will only happen off the back of individual effort. Health isn’t something that can be fixed, and recovery is hard. Our health is the most valuable and precious commodity we will ever possess; how can we not take responsibility for that? *Just to clarify, this is a reference to the men’s game 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 [https://mskmag.substack.com/subscribe?utm_medium=podcast&utm_campaign=CTA_2]