Show Notes
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Picture it. The next patient is walking through the door and you don’t have a f*****g clue what to do with them. You just hope they don’t ask too many questions. I know I’ve been there… have you? Thankfully, less so in recent years, although I certainly do still have those moments! I’m experienced enough now however to openly acknowledge this and save myself the later embarrassment showing that I was winging it. An embarrassment that I endured time and time again in my early years as a physiotherapist. “Patient’s had an ankle fusion? Hmm, not sure what that is and no real time to understand it or discuss it with my senior so to hell with it, I’ll just fall back onto pushing and rubbing it a bit.” This is the case that stands out to me when I reflect back. I cringe every time. Trying to restore movement in a joint that had been excised, packed with bone graft and held firmly together with a nail. What an idiot! This is an uncanny representation of that fateful day! Overconfidence in special tests, diagnosing everyone with complex biomechanical issues that existed purely in my own head and not having the foggiest idea of what would happen in the world of orthopaedics should my patient fail to improve. The list could go on. And the way I see it, there are two possibilities here: * I was in the bottom quartile when it came to knowledge after coming out of university and too arrogant to even think that this was a possibility. * I was simply not prepared in the right way to be as effective, accurate or aware of my own limitations as I needed to be in the complex world of MSK. Those who know me personally and read this will delight in telling me it’s number 1 and that they never experienced anything like what I’ve laid out above. And to them I say; it’s okay, they’re only my feelings you’ve hurt and I’m sure they’ll heal… and also you’re lying. Experiences just like mine are extremely common. Based on the conversations I have had, I would actually go as far as to say it is the normal experience for new graduates in MSK! But is it a sign of personal failure? Absolutely not. It’s actually a fairly predictable situation. Yet, we seem to be okay with it as a profession; regardless of the negative impact that it has on the clinician who might experience high levels of stress, the patient who has waited months or invested their own money to come and see a specialist, or the reputation of the profession when these two previous scenarios mix and leave a sour taste in everyone’s mouth. In this article, I want to challenge the status quo of MSK training and practice with a particular nod to the pre-registration degree, whether that be undergraduate or pre-registration masters. I will argue that it is no longer fit for purpose and can actually be counter-productive to producing good quality MSK clinicians.
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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
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
This is a free preview of a paid episode. To hear more, visit mskmag.substack.com