I’ve been there myself, not having a f*****g clue what a certain condition was, sat at a computer in a chaotic physiotherapy department, frantically searching for any explanation that sounded credible enough to pass on to my patient.

A patient who, it’s worth mentioning, has been waiting months to speak to someone about their hip pain. Pain that was dragging them down, straining their relationships, and making their working life increasingly difficult.

I would bet my house this sounds familiar to you! And to a degree, it’s inescapable. After 11 years of practice and narrowing my scope to focus on lower limb conditions, I still encounter unknowns.

But this scenario remains a persistent problem for newly qualified physiotherapists entering their first MSK role... and sometimes well into higher bands in the UK (band 5 being the graduate entry point for those joining us from abroad)

The problem is not that newly qualified physiotherapists aren’t encyclopaedias or walking audiobooks of Brukner and Khan’s Clinical Sports Medicine, volume 6! That’s the wrong measure of quality in my opinion. The better measure is how consistently our graduates are able to practise the fundamentals of MSK care accurately, and with confidence.

Because these moments, where clinicians scramble to retain credibility in front of patients who reasonably expect expertise in their management, are not signs of personal failure.

I think they are predictable outcomes of how we currently educate, deploy, and regulate physiotherapists.

In this blog, I want to challenge the status quo of MSK practice in the UK to provoke thought and argue that meaningful change is probably needed. I also want to be clear: I am not assigning blame to individuals or organisations (including individuals practicing, universities or those that currently are involved in university programme planning / delivery). Our current system has emerged from the multiple constraints imposed on it from the past.

But “that’s how we’ve always done it” has never been a serious argument for how we should continue; and if you have read my blog on systems, you will know that the emergent behaviour should be adaptable in line with the current constraints acting on that system.

Who decides what the baseline is?

Physiotherapy in the UK is statutorily regulated profession which essentially means that there are laws in place to ensure we as physiotherapists meet defined standards of practice. The main aim of this requirement is public protection from unqualified, unsafe or unethical practitioners.

This is what we pay the Health and Care Professions Council (HCPC) for; to 'regulate' us. That is actually a huge topic to explore, but for another day.

On top of the HCPC, we have the Chartered Society of Physiotherapy (CSP) which, unlike the HCPC, is not a statutory regulator, but a trade union that has voluntary membership, which advocates for development of the profession as well as the important trade union stuff of workplace representation and legal / professional protection.

So when it comes to the legal baseline and quality assurance, it is overwhelmingly the HCPC that controls this, and as I mentioned above, the goal is patient safety.

Obviously, an incredibly important objective. But... potentially a bit vague (there is obviously more depth within their standards of proficiency) and more importantly, not really focused on developing specific guidelines when it comes to ensuring an acceptable quality of MSK care. There are specific regulations a university has to meet for a physiotherapy course to be accredited, but this is less focused on specific subject content and more on the structure of the course and ensuring there is evidence to cover the mandatory things that patient safety is contingent on.

And this is evident in practice, I am HCPC registered however when I was a band 5 attempted manual therapy on a recently fused ankle joint. In reality, not really going to cause a non-union or adverse patient outcome but certainly a waste of time and exposes a severe lack of clinical reasoning. So... safe because there was a literal metal nail keeping the fusion in place, but not really that effective? There are tonnes of examples I could go into from personal experience and stories I've heard from others; and I'm sure you have a few yourself also.

What put me (and every other new graduate in MSK) in this position? Well, it was my undergraduate university degree which crammed in a really broad curriculum and my equally broad clinical placements.

1000 hours sounds intensive but it could actually mean 200 hours or around 5 weeks of MSK specific care. At worst, it's now not uncommon to hear a student graduating with NO MSK placement experience.

How is that fair for anyone, clinician or patient, when it comes to an MSK consultation?

We are creating 'generalist' physiotherapists

My stance is that for what MSK care needs, the current production of physiotherapists is actually counter-productive. And it seems like we train aspiring physiotherapists in a multitude of areas (MSK, Neuro, Respiratory at a minimum) because... that's what we have always done?

Current workforces in the NHS are built on needing band 5 physiotherapists to fill the rota which extends across all domains. Is this what drives the broad nature of the undergraduate or pre-registration masters degrees? Workforce demands?

If so, minimum safe staffing levels at each department and performance data of patient contacts or throughput are probably what policy makers are most interested in - and I get that to a certain extent.

In my conversations whilst writing this blog I have also come across discussions about the benefits to MSK patients of having some training or awareness of other pathologies (e.g. neurological conditions). A line of argument that I can completely see the truth and value in (even though if not practiced regularly this knowledge will fade over time), but are also patients that are relatively small in number to the MSK patients without these conditions.

The question I will ask is this; are workforce demands, or simply keeping the status quo a good enough reason to continue creating physiotherapists who are unlikely to cause harm but also, unlikely to be hugely effective (in all areas, not just MSK)?

I would challenge that, much like treating a patient, we should start with the end goal. That means understanding the problem. It will come as no surprise that multiple bodies (UK government musculoskeletal health reports, Versus Arthritis, Arthritis UK, WHO) have noted musculoskeletal disorders to be one of the top leading causes of disability within the UK, but also worldwide.

In the 'State of Musculoskeletal Health Report 2025', MSK conditions account for 21% of years lived with disability (YLD) across ALL health conditions that worsen someones quality of life. That's HUGE. More specifically, lower back pain is the single leading cause of YLD's accounting for 10% across all health conditions.

The figures in the above infographic are likely not of any surprise in terms of the variety of ways that living with a long term MSK condition can impact someone, but it does seem to bring it home about the magnitude of the problem that we have as a society. These are all things that we should be able to positively influence on a personal level for people.

Thinking further afield, to the economic situation, things look equally concerning.

13% of sickness in the NHS from August 2023 to July 2024 was attributed to MSK conditions which equates to 3,460,166 sick days.

In the same time period, 52% of fit notes written by GP's for MSK conditions equated to more than 5 weeks off work.

There are plenty more statistics we could throw in here, and we haven't even discussed how people with OA are significantly more likely to develop other health conditions including Type 2 Diabetes (61% higher risk), Cardiovascular health issues (24% higher risk) which are all worsening quality of life and increasing the burden on our healthcare system and economy.

Point made?

Hopefully the statistics provided from this Arthritis UK report help us understand the end goal a bit better. The whole point of healthcare systems is to improve the overall health of the population and the fact that the state of musculoskeletal health right now is pretty appalling, and deteriorating, should be enough for governing bodies to realise that the status quo isn't working across a lot of sectors.

I'm not here to claim that MSK physiotherapists can resolve this issue, it is an extremely complex and multi-faceted outcome that is contributed from everything from family experiences to political manifestos. However, MSK physiotherapists do play a key part. On an individual level, helping people through injuries to stay active, in work, out socialising, not letting them easily throw in the towel. MSK physiotherapists have also branched out to do amazing research which can inform both individual practice and public policy. We have incredible value.

So why does it take a few years for us to learn to swim after university has chucked us straight into the deep end, to develop the skills required to make consistently valuable contributions?

It seems really strange, especially when you realise that MSK specialism and pathways that place physiotherapists at the forefront of MSK care are already in place. First Contact Practitioners are now common place in primary care settings to offer expert advice on musculoskeletal management and highlight the patients that need medical attention to GP's.

Advanced practice roles within secondary care are hugely important, offering effective triage to patients through collaboration with multiple specialities and requesting and interpreting investigations.

Although exact figures are hard to come by, MSK conditions are the biggest type of condition that physiotherapists seeand it is likely that a very large proportion of physiotherapists in the UK end up working in MSK.

In many ways, MSK practice is already functioning as a distinct profession in itself.

So why do we pretend that its not?

The idea of a generalist physiotherapist is deeply embedded within our current system, is culturally valued, and even appealing to early-career (or pre-application) physiotherapists who are unsure on the direction they want to take (this was me!). However, the vast majority of us end up 'specialising' not long after graduating anyway, in which case you could argue that a large proportion of time spent learning other things was essentially just time wasted.

You could also argue... that the current undergraduate and pre-registration training is actually creating the problem.

What if the clinical need drove the training, rather than tradition?

Just imagine that your programme at university didn't have just 'MSK' as one stream of learning but actually had an entire curriculum that could be devoted to all aspects of MSK, with enough time devoted to it to be effective.

• Truly studying the pathophysiology of the most common conditions rather than a quick google before your next patient comes in

• Learning the nuances of communication and putting it into practice with 1000 placement hours dedicated solely to MSK practice

• Critically reasoning why and when you would use exercise, manual therapy and dynamometry instead of just learning how to give it out

• Learning the basics of the what, when, why of different imaging modalities and what patient escalation might entail from an orthopaedic / rheumatology / pain management perspective.

As I stated at the start of the blog, this is not about trying to make all graduates a specialist from day one. It's about raising the bar when it comes to competence. Just imagine what a better place we could be in if the amount of time needed to be effective in delivering MSK care was actually provided before you even graduate, rather than essentially being on a post-graduate apprenticeship for an unspecified amount of time (thanks to minimal post-gradaute regulation... a post for another time I think!)

I had initially titled this blog 'MSK specialism is a post-graduate pursuit... Oh yeah? Says who?' in full knowledge I am unlikely to find any one person or institute that has actually said this. But as the saying goes... actions speak louder than words. And the current actions and output of our system are screaming that MSK specialism is a post-graduate pursuit.

If you can feel yourself agreeing with some of the points I have made in this blog, then the question is not 'How can we help graduates improve quicker'... it's actually

'Why are we happy with a system that makes starting to practice MSK care an inevitable struggle?'

So, let me end by asking you a few questions:

1. Do we owe our patients, the healthcare service and the economy more than 'safe' care?

2. Do we owe our graduate physios more than just the opportunity to try and survive?

3. Do we owe the profession more than tradition?

Thanks for reading, and please do vote on the poll, leave comments and reach out so we can discuss.

Jeff