Show Notes
Over the past decade few developments have reshaped UK musculoskeletal (MSK) care as profoundly as the rise of First Contact Practitioners (FCPs) in primary care. What began as a pragmatic response to workforce pressure has quietly evolved into something far more significant: advanced-level clinical decision-making at the very forefront of the system. In many ways FCPs have changed the front door of the NHS. Patients now access specialist MSK expertise earlier. GPs are better supported. Pathways move faster. Risk is managed closer to the point of presentation. When the model works well, the whole system works smarter. But as the FCP role has expanded, it has become increasingly clear that the expectations placed on many FCPs now look very much like those of advanced practitioners, even though, formally, the role is rarely defined that way. For me, that creates a tension within the profession. Because the future of MSK care will not be shaped simply by how many FCPs we employ, but by how well we develop, support, and lead the clinicians working at the front line of primary care, and how well the rest of the system keeps pace with what that front line now requires. From workforce solution to advanced clinical reality The FCP model was born out of necessity. General practice was under intense pressure. MSK presentations were consuming huge clinical capacity. Waiting lists were growing. Patients were often being referred into pathways that felt slow, fragmented, and overly medicalised. Putting experienced MSK clinicians at the point of first contact made sense, and in many places it has worked brilliantly. Today, FCPs are routinely: * Assessing undifferentiated presentations * Identifying serious pathology early * Making referral decisions * Managing clinical uncertainty in real time * Shaping patient beliefs at the very start of their journey * Influencing practice-wide MSK decision-making. This is not just triage or filtering demand. This is advanced-level practice in one of the most pressured environments in the NHS. MSK in primary care has become a setting where judgement matters as much as skill. Where pattern recognition, risk stratification, and professional confidence are tested daily. Where the first conversation often determines the entire trajectory of someone’s care. And yet despite this, we still tend to talk about FCPs as if they are primarily a service solution rather than a professional group operating at (or rapidly moving towards) advanced practice. That gap between what the role is called and what the role actually requires should not be ignored. What’s working well Across the UK, there are outstanding examples of FCP-led MSK services. Where advanced-level practice is properly supported in primary care, three things consistently stand out. 1. Right expertise, right time When skilled MSK clinicians see patients first, the impact is immediate. We see fewer unnecessary scans, more appropriate referrals, earlier reassurance, and high levels of patient satisfaction [1]. Having specialist MSK expertise at the front door reshapes what ‘good MSK care’ looks like. 2. Stability in the grey zones Primary care is full of grey zones. MSK presentations are rarely neat. Pain is complex. Fear is common. Red flag pathologies are rare, but very much there. What experienced clinicians bring here is not certainty, but calm judgement. Confidence that comes from experience, pattern recognition, and knowing when not to act. That confidence reduces defensive referrals, unnecessary imaging, clinician anxiety, and patient fear. In this way, advanced MSK practice does more than assess and manage conditions. It helps to stabilise the system. 3. FCPs as translators of MSK thinking One of the most underestimated contributions of FCPs is their educational influence. Every day, they reframe beliefs and myths. They support MDT colleagues with MSK reasoning. They influence how practices triage. They translate specialist MSK knowledge across prim
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It always struck me as bizarre that sports medicine and musculoskeletal specialties deal with pain and dysfunction from head to toe in the human body, yet offer little health literacy or inclusion of the pelvic floor. Traditionally considered taboo and someone else’s remit, men and women with issues affecting the pelvic floor have largely suffered in silence. Thankfully, change is afoot, and healthcare is finally evolving. There is much more awareness, inclusion, and understanding of this unique body area and the role that it plays. For anyone playing catch up, the pelvic floor is a group of muscles spanning the base of the pelvic outlet in layers. While both men and women have a pelvic floor, the pelvic outlet is wider in females than in males and it also contains an extra orifice – the vagina [1]. That’s right, we went there. We said the ‘V’ word. Because just like vulva, or vestibule, the vagina is simply an anatomical term. It needn’t be embarrassing or taboo. Some of you will be long enough in the tooth to remember when the word ‘breast’ was taboo. However, with healthcare campaigns for breast cancer and breastfeeding, this term became an anatomical norm. We need to do the same for the pelvic floor and its related anatomy and physiology. What does the pelvic floor do? In both men and women, the pelvic floor serves to control the bladder and bowel (maintain continence), empty the bladder and bowel (voiding and defecation) and support sexual function (arousal and climax). In women, the pelvic floor also plays an important role in pelvic organ support. Remember that extra orifice I mentioned earlier…well this area is high risk for connective tissue laxity and defects meaning that the pelvic organs (bladder, uterus, rectum) can descend into the vaginal cavity causing symptoms of heaviness, pressure and a sensation of ‘something in the vagina’. What are the signs and symptoms of pelvic floor dysfunction? If the pelvic floor is not doing its job, any of its roles can become compromised. This may manifest in leaking from the bladder or bowel, inability to fully empty the bladder or bowel, pain ‘down there’, sexual dysfunction (compromised erection, dyspareunia, pain with climax) or heaviness and pressure in the vaginal region (for women) [2]. A full list of sex-specific signs and symptoms of pelvic floor dysfunction can be seen in Table 1. Table 1 - signs and symptoms of pelvic floor dysfunction in men and women Who gets pelvic floor dysfunction? Pelvic floor dysfunction can affect any man, woman or child, however it is particularly problematic for women, especially during transitional life events, such as pregnancy/childbirth and the menopause [1]. One in three women will experience pelvic floor dysfunction [3] and for those that engage in sport, the prevalence of symptoms varies according to the load demands of the activity. For example 61% of netballers leak urine [4], up to 43% of female rugby players leak [5], and 32% of gymnasts experience incontinence [6]. Structural changes associated with vaginal childbirth and aging, as well as lower levels of oestrogen to lubricate and bulk out the tissues can increase the odds of experiencing pelvic floor dysfunction. However, even young adolescent females can leak urine due to the load demands of their sport. For example, in athletics and gymnastics, stress urinary incontinence (the involuntary leakage of urine during activities involving high levels of intra-abdominal pressure) is commonly experienced. Yet no-one is doing anything about it. No one is screening. No one is signposting. No one is educating these younger athletes that pelvic floor symptoms are not to be expected and normalised. Or that they simply indicate that the sporting demands exceed the load capacity at the pelvic floor. If this was any other area of sports or MSK practice, would we settle for a load capacity that does not meet the demands of the sport?! Why is this relevant to every therapist, no matter their di
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This is a free preview of a paid episode. To hear more, visit mskmag.substack.com
This is a free preview of a paid episode. To hear more, visit mskmag.substack.com
This is a free preview of a paid episode. To hear more, visit mskmag.substack.com