Acromioclavicular joint injuries


The acromioclavicular (AC) joint is a diarthrodial joint that anchors the clavicle to the scapula and shoulder girdle, it helps distribute forces from the upper extremities to the axial skeleton.[1-4] Static stability at the AC-joint is achieved via the AC-ligaments, capsule, and coracoclavicular (CC) ligaments, whilst dynamic stability is provided by the Deltoid and Trapezius muscles.[1-5] As the AC-joint lies relatively subcutaneously there is little protection from soft tissues, and as such is prone to injury; specifically within contact sports,[2,5-6] i.e. via trauma.  It is reported that AC-joint injuries comprise 9-12% of all injuries to the shoulder girdle,[2-4,6] with males in their 20’s having the highest rate of injury.[2-3,6]


As with most traumatic injuries, the AC-joint can be injured by direct or indirect trauma. Direct trauma to the AC-joint is caused when a person lands on the point of their shoulder, as seen in multiple collision sports; which forces the acromion inferiorly and medially.[2-4] Indirect trauma is caused when a person falls on an outstretched hand (FOOSH), and the force is transmitted up the arm forcing the humeral head into the acromion.[1-3] Whether the injury was cause by direct or indirect trauma matters not, the classification is based on structural involvement and displacement present; therefore higher levels of force involved will lead to a higher classification.

There are many methods of classifying ligament or muscle injuries throughout the literature, [7] with the research surrounding AC-joints’ being no different. The most commonly recognized classification is known as the Rockwood classification[1,4] (Table 1). The Rockwood grading system is based on physical and radiographic findings,[1-6] whereas in the clinic it would be down to the level of visual displacement and painful areas upon palpation. Throughout the classifications, the higher classifications of injury are shown to have greater ligamentous involvement and a greater displacement present.

Table 1: AC-joint injury – Rockwood classifications[1,4]

Best treatment for injuries I, II, and IV-VI has been clearly established within the literature.[1-6] Type I and II injuries are treated conservatively with treatment commencing as comfort allows, as for type IV-VI injuries the literature states that open reduction and internal fixation with ligament repair/reconstruction is the treatment which provides best prognosis. However, these authors all agree that type III injuries must be taken on a case-by-case basis. Current trends exist in the literature to show that conservative management provides an earlier return to work and sport[4] with Bontempo and Mazzocca[3] stating that: at a 2 year follow up, non-operatively versus operatively treated type III injuries had no difference in strength after 2 years. That being said Bannister et al. (1989) as cited by Lemos[1] state that those with a displacement greater than 2cm did better with operative intervention, while Bontempo and Mazzocca[3] go on to say that surgery may be indicated in those whose symptoms persist after a full course of rehabilitation.

The primary aim of rehabilitation for an AC-joint injury is to restore pain free Range of Motion (ROM), how quickly this happens will depend on the type of injury and whether this is the first or a subsequent injury. Rehabilitation programs involve modification of the patients’ work and daily activities in the initial phase before gradually introducing and progressing exercises.[1-6] For non-operative treatment, Bontempo and Mazzocca[3] proposed an algorithm (Figure 1), which showed that athletes should go through a 3-month functional rehab program before surgery is considered.


Figure 1: Non-Operative treatment algorithm proposed by Bontempo and Mazzocca[3]

Case Study

As an example, we will take a patient with a Grade II injury: they have a decreased ROM across all shoulder movements, an associated decrease in strength, with pain and laxity present. After assessment the patient would be advised to continue with the P.O.L.I.C.E (Protection, Optimal Loading, Ice, Compression, Elevation) principle[8] and to reduce the amount of overhead and heavy work conducted,[1-6] whilst avoiding competitive sport and heavy lifting until cleared.[6] Initially the patient would be placed in a broad arm sling and advised to wear it regularly over the first 1-2 weeks; this advice would be accompanied by passive ROM exercises to prevent the shoulder from becoming stiff whilst in the sling.


When pain starts to subside, patients would be advised to wean themselves out of the sling by trying to use their arm for light daily activities. Whilst increasing their ROM exercises, and to begin replacing passive ROM with active assisted exercises and isometric holds throughout range;[2,5] this would include hold-relax proprioceptive neuromuscular facilitation (PNF) patterns for the upper limb.[9]

Once full pain-free ROM has been achieved the patient would begin an upper limb rehabilitation program to strengthen the AC-joint and surrounding structures; to provide additional pain relief during the early stages of the rehab program the AC-joint may be taped.[5-6,10-11] Strength exercises primarily focus on the trapezius and deltoid muscles (table 2), while elements of neuromuscular control (NMC)[5,12-13] would be introduced to strengthen the rotator cuff and additional musculature about the scapulae (table 3).

Table 2: examples of strength rehabilitation exercises

Table 3: examples of NMC rehabilitation exercises


To summarize, the AC-joint is a very superficial joint prone to traumatic injuries, for example in contact sports, the higher the levels of force in the injury will generally lead to a higher classification of injury; with it comprising 9-12% of all injuries to the shoulder girdle,[2-4, 6] and males in their 20’s having the highest rate of injury.[2, 4, 6]. The primary method for classifying AC-joint injuries involves both physical and radiographic findings, however in the clinic the grading will rely on the level of visual displacement and painful areas on palpation with Higher levels of force generally leading to a higher classification of injury. The primary aim of rehabilitation for an AC-joint injury is to restore pain free ROM, how quickly this happens will depend on the type of injury and whether this is the first or a subsequent injury. Although type III injuries provide an area of contention within the research, the majority of rehabilitation programs follow a conservative approach similar to that of type I and II injuries. For an injury to the AC-joint, a rehabilitation program will include: modification of the patients’ work and daily activities in the initial phase, before gradually introducing and progressing exercises. This along with NMC and dynamic stabilising exercises would assist in not just rehabilitating the primary injury but assist in preventing further injuries to the AC-joint.




  1. Lemos, M.J., 1998. The evaluation and treatment of the inured acromioclaviculae joint in athletes. The American Journal of Sports Medicine, 26(1), pp. 137-144.
  2. White, B., Epstein, D., Sanders, S. and Rokito, A., 2008. Acute acromioclavicular injuries in adults. Orthopaedics, 31(12), pp. 1219-1226.
  3. Bontempo, N.A. and Mazzocca, A.D., 2010. Biomechanics and treatment of acromioclavicular and sternoclavicular joint injuries. British Journal of Sports Medicine, 44(5), pp. 361-369.
  4. Wright, A.P., MacLeod, I.A.R. and Talwalker, S.C., 2010. Disorders of the acromioclavicular joint and distal clavicle. Orthopaedics and Trauma, 25(1), pp. 30-36.
  5. Brukner, P. and Khan, K. 2013. Clinical sports medicine. 4th Australia: McGraw-Hill Education.
  6. Fraser-Moodie, J.A., Shortt, N.L. and Robinson, C.M., 2008. Injuries to the acromioclavicular joint. The Journal of Bone & Joint Surgery, 90(6), pp. 697-707.
  7. Mueller-Wohlfahrt, H.W., Haensel, L., Mithoefer, K., Ekstrand, J., English, B., McNally, S., Orchard, J., Van Dijk, C.N., Kerkhoffs, G.M., Schmasch, P., Blottner, D., Swaerd, L., Goedhart, E. and Ueblacker, P., 2013. Terminology and classification of muscle injuries in sport: The Munich consensus statement. British Journal of Sports Medicine, 47(6), pp. 342-350.
  8. Bleakley, C.M., Glasgow, P. and MacAuley, D.C., 2012. PRICE needs updating, should we call the POLICE? British Journal of Sports Medicine, 46(4), pp. 220-221.
  9. Kwak, D.H. and Ryu, Y.U., 2015. Applying proprioceptive neuromuscular facilitation stretching: optimal contraction intensity to attain the maximum increase in range of motion in young males. Journal of Physical Therapy Science, 27(7), pp. 2129-2132.
  10. Shamus, J.L. and Shamus, E.C., 1997. A taping technique for the treatment of acromioclavicular joint sprains: a case study. Journal of Orthopaedic and Sports Physical Therapy, 25(6), pp. 390-394.
  11. Kneeshaw, D., 2002. Shoulder taping in the clinical setting. Journal of Bodywork and Movement Therapies, 6(1), pp. 2-8.
  12. Gutierrez, G.M., Kaminski, T.W. and Douex, A.T., 2009. Neuromuscular control and ankle instability. PM & R: The Journal of Injury, Function, and Rehabilitation, 1(4), pp. 359-365.
  13. Herrington, L., Myer, G. and Horsley, I. 2013. Task based rehabilitation protocol for elite athletes following anterior cruciate ligament reconstruction: a clinical commentary. Physical Therapy in Sport, 14(4), 188-198.

How to Reactivate Past Clients Using Special Offers

How to Reactivate Past Clients Using Special Offers

Do you want to fill your appointment books? Then, let us discuss the opportunity right under your nose which is, Reactivating Past Clients.

Past clients already, know, like and trust you, so they are more likely to return for your services. You can use your time, money and effort more effectively, often with more immediate results when you focus on the people already in your community or database.

What do you mean Reactivate?

Any client who does not have future appointments booked needs to be nurtured as much as the clients who do. Effective recall and reactivation processes enable your clinic to maintain those relationships and are vital for the ongoing health of your client, and your business.

Why is Reactivation important?

  1. Perceived indifference is a killer. 68% of clients ‘leave’ because they perceive that it doesn’t matter to you if they return or not. It’s important to show how much you care by nurturing them with regular contact after each appointment, especially if they don’t have any future appointments booked.
  2. You are the trusted advisor in your client’s health, and you have the opportunity to recommend the best management plan for a clear outcome. If client’s don’t maintain their future appointments, your effectiveness as a health professional is reduced.
  3. You need a safety net to ensure clients are carefully nurtured through their journey and that they don’t experience a lapse of care, ensuring the highest likelihood of success.
  4. It’s much easier and cheaper to provide optimum care outcomes for your existing clients than it is to find a new client. You’ve already established rapport, likeability, and trust, and good systems around recalls and reactivation enable you to find new and better ways to serve the needs of your clients.

How can I Reactivate clients?

These processes apply to clients who have no future appointment booked. At various intervals, they will need to be contacted, and you can choose the frequency.

Don’t worry if you feel you are nagging clients. People are generally busy, and will more likely appreciate your attention to follow up. You can always ask for forgiveness if a client is feeling hassled.

If a client cancels and is unable to reschedule right away you might offer to place them on a recall list, offering to contact them in 2 weeks, or perhaps 2 months, depending on the situation.

Example recall schedule:

  • 2-week recall (phone call or SMS)
  • 2-month recall (Phone call, SMS or email)

If you attempt to contact, or if the recall is unsuccessful, then your safety net is the Reactivation Schedule, where the client is contacted at regular intervals with information, special offers, or personal notes inviting them to return to the clinic.

Example Reactivation schedule:

  • Reactivation SMS at 3 months
  • Reactivation email at 6 months
  • Reactivation letter at 12,18 months
  • Reactivation letter at 2,3,4 years (include special offer and newsletter)

Method #1 – Email

  • Email is a highly leveraged and automated process, enabling you to send a series of broadcasts at the scheduled time.
  • Typically 2-3 emails at the time of the recall broadcast are best for exposure because some emails may be missed amongst the client’s inbox/junk/spam or other folders.
  • Email is quick, cheap and you can often get analytics on how effective each broadcast has been.

Method #2 – Posted Letter

  • Using Letters means we can add a personal feel to our communication with an added handwritten note or personal signature.
  • You also have the opportunity to include marketing material, vouchers, or printed newsletters
  • Printing, folding, packing and delivering letters takes time and money, but the advantage is household letterboxes are not as cluttered as email inboxes, and the success rate can be much higher.
  • Letters can be slower, with no automated analytics on effectiveness, though they do add a personal touch, and can help keep your database up to date with current home addresses.

Method #3 – Phone Call

  • This can be the most effective way connect with your clients, however, it relies on having them answer the phone.
  • If you need to leave a message, do so, and then follow up with either of the other methods to ensure the client is engaged (e.g. send an email with a mention of the missed call or voicemail).
  • Practitioners who make these calls can get caught delivering consultations over the phone, so our suggestion would be for a trained member of your admin team to deliver these calls. The calls can be framed as a courtesy call to check in on the patient and extend the invitation and to help arrange their next appointment time.

Method #4 – SMS Message

  • This is an immediate and effective way to engage with your clients.
  • It’s hard to convey tone through a text message, but with the right words you can achieve the desired result.
  • Make sure the message has a clear call to action and a simple process to act. Complexity will catch you out when you are only playing with a few characters in the message.

Method #5 – Push Notifications (via mobile app)

  • If your clinic has a mobile app, you can engage your clients with a push notification
  • Straight to the palm of your client’s hand, this is an interactive way to readily engage your clients.
  • You can announce new products and services and invite people to book appointments.
  • There are limitations around the number of active app users, so it’s best to use this in conjunction with other methods.

What to do

  • Choose your audience
    • Database segmentation using your practice management software helps you deliver personalized and specific messages to the individual. This is particularly important when you’re communicating with a large audience all at once.
  • Select your Reactivation Frequency
    • As a rule of thumb, we suggest starting the reactivation process with any client who has not attended your clinic for at most 6 months and has no future appointment booked. If this is time frame is too short for your particular profession, you can still contact your client to send useful information, and reserve the invitation to book an appointment until the required time.
  • Select your Reactivation method
    • Choose from the top 5 methods above
  • Create your invitation and offer within the Reactivation
    • Use a special offer as a low barrier to entry, making it really attractive for them to return for an appointment.
    • Advise clients on the new and better ways you can serve their health and body. Tell them of the fantastic new skills or technologies you now have as a result of your continuing professional development and let them know how it can help them. Offer them the latest treatment modalities and access to specialized equipment that you have in your clinic so that they can optimize their health.
  • Send the Reactivation message
    • Remember to personalize it
  • Identify a tracking method
    • It’s always useful to be able to track how effective each reactivation campaign is.
    • To review results of each broadcast, you should identify a special code or appointment type that you can use to measure the rebooking.
    • Measure the impact with Clinic Excellence Indicators such as Rebooking Percentage and Patient Visit Average (PVA).

Making it successful!

  • The key is to get clients committing to a regular routine of care… not a once off. The intention is to refine, create or continue the optimal care plan to not only manage, also optimize their health now and into the future. This is best done in the form of a written management plan outlining the next 3 visits/reviews/check up/treatments. There could be 3 weeks or 3 months between the visits, it doesn’t matter, you just need to give the client a plan to work toward.

In Summary

Reactivations allow you to:

  1. Follow up client health to maintain it
    1. Check their progress on their initial complaint that you helped them with
    2. Check to see if they are still functioning ‘better’ following your help
    3. Check to see that they are able to move freely, without pain or restriction in other areas of their body so that they do their best to avoid relapse or other problems
  2. Follow up client health to optimize it
    1. Help them prepare for an event or activity on their calendar
    2. Help them perform at a higher level each day so that they can be their best and live their ever improving potential
    3. Help them reach a milestone or goal so that they experience the abundance of their body

So reactivations are important for client health and for filling your appointment books!

Remember that when you invite clients to accept your offer, that it should be truthful and the terms and conditions should be clearly stated in the advertisement.

Do Reactivations regularly and allow your clinic and clients to thrive.

Until next time, continue to consult with passion and serve with care.



We have a community of health professionals from around the world who are governed by various rules and regulations. We suggest you get familiar and comply with those which apply to you so that you advertise legally and ethically.

Opinions expressed by physiogramworld contributors are their own.

Ankle ligament injuries: Assessment and Rehabilitation


Lateral ankle ligament sprains are the most common injury affecting both general and athletic populations.[1-7] Within the UK and the US approximately 5,000 and 27,000 injuries respectively occur per day,[1] with research showing that the anterior talofibular ligament (ATFL) is injured most frequently.[1-2] The ATFL connects the lateral malleolus to the neck of the talus, forming part of the lateral ligamentous structure of the ankle joint; alongside the calcaneofibular and posterior talofibular ligaments (PTFL).[1,5,9] Due to the biomechanics of the ankle joint, as plantar flexion (PF) increases the soft tissues are more susceptible to strain/injury;[1] with most sprains occurring in PF, adduction and inversion, leading the ATFL to be injured before any other ligament;[1,5] the classic ‘rolled ankle’ or ‘going over on your ankle’


In the acute setting, to assess the ankle, simply placing the ankle into: PF, abduction and inversion will be sufficient to elicit pain in the ATFL – this is if the patient will let you. This in conjunction with the anterior draw test[2] and palpation can lead to the diagnosis of an injury to the ATFL. In addition to this assessment a clinician should also check the syndesmosis, via the syndesmosis squeeze test,[9] and assess for creptius at the foot/ankle: for possible Lisfranc injury or a 5th metatarsal fracture, and for crepitus at proximal fibula: attempting to rule out a Maisonneuve fracture. In the acute setting the Owatta ankle rules [1,5,10,11] can be applied to help the clinician decided if an ankle x-ray is required. Research suggests, that due to the bodies healing mechanisms initial soft tissue injury management, P.O.L.I.C.E (Protection, Optimal Loading, Ice, Compression and Elevation),[12] should be commenced and a more thorough assessment should be completed 4 days post injury.[1,4] There are several grading systems available,[1,13] for musculoskeletal injuries and are dependent on the clinician present as to which is used.


As research suggests,[1,3-5,14] the treatment of choice for this type of injury should start with P.O.L.I.CE, to reduce pain and swelling; continuing with exercises when able. These early mobilisation exercises should take the form of gentle active range of motion (ROM) exercises e.g. plantar flexion, dorsiflexion, inversion, and eversion.[1,3-5] Early mobilisation provides controlled stresses to the ankle joint and has been shown to speed up the recovery of acute ankle injuries.[1] My personal favourite to say to patients for ROM exercises, is to get them to write the alphabet or spell their name with their foot. To maintain cardiovascular fitness and to help work the ankle functionally, although in a controlled manner, one can use the stationary bike or elliptical.


When the patient is able to progress with their exercises, the progressions should always be functional in nature, with an element of proprioception/neuromuscular control (NMC).[1,3-5] Due to the importance of restoring NMC,[3,5] NMC exercises should be afforded their own time slot; as insufficient NMC is a contributing factor to both initial and secondary injuries.[15] Functional treatment is based on the healing process of a ligament: during the first 3 weeks as new collagen tissue forms it is necessary to prevent unwanted inversion as this will lead to a weaker collagen being laid down, after 3 weeks the collagen begins to mature and responds to controlled stresses by correcting fibre alignment.[1] The collagen will continue maturing, with a return to activities expected at approximately 4-8 weeks.[1] Manual mobilisations, ultrasound, laser and electrotherapy were shown to have limited/no added value to ankle ligament rehabilitation.[4]


Rehabilitation exercises, no matter their guise; be it strength, flexibility, or NMC, are always commenced on a stable surface. During a NMC session, the goal is to provide greater kinesthesia through better communication between the neural and muscular systems. Therefore to progress NMC exercises from a stable base, the exercise could include external perturbations (catching/throwing an object), be conducted on an unstable surface (foam pad/mat/beam), having a flight phase included,[16-17] or by combining progressions. An example here would be a single leg stand; this can be progressed by: throwing and catching a ball (reaching out of the base of support), standing on an unstable surface, and standing on an unstable surface whilst throwing and catching a ball.


An example rehabilitative exercise for the ATFL is the Step-up; whilst this may primarily be used for strength, it can have a great NMC adage. The step-up should only be commenced once the patient is: 1) fully weight bearing, 2) able to take their full weight on a single leg, and 3) is confident in stepping up through their injured side. Initially the step-up can be conducted onto a shallow box (Figure 1), which can be made higher (Figure 2) as the patient progresses.

Figure-1- Shallow-box
Figure 1: Shallow box
Figure 2: Deeper box


  1. To start, the patient will stand facing the box (Figure 3), before stepping onto it leading with the injured side (Figure 4). The patient will stand up achieving full extension (Figure 5), before stepping back down in a controlled manner.
    Figure 3: Start position
    Figure- 4-Stepping- onto- box
    Figure 4: Stepping onto box
    Figure 5: Top position
    Figure 5: Top position

2.Adding a foam pad/mat onto the top of the box to create an unstable surface (Figure 6), then continuing as in 1.


Figure 6: Foam pad progression
Figure 6: Foam pad progression

3. Stable box; upon stepping up onto the box, adding in a hip/knee drive of the contralateral leg (Figure 7)

Figure 7: Hip/knee drive progression
Figure 7: Hip/knee drive progression

4. Foam pad/mat on box; stepping up onto the box with a hip/knee drive of the contralateral leg (Figure 8)

Figure 8: Foam pad + hip/knee drive progression
Figure 8: Foam pad + hip/knee drive progression

5. Stable box, hip/knee drive of the contralateral leg: achieving flight phase (Figure 9)

Figure 9: Flight phase progression
Figure 9: Flight phase progression

6. Foam pad/mat on box, hip/knee drive of the contralateral leg: achieving flight phase (Figure 10)

Figure 10: Foam pad + flight phase progression
Figure 10: Foam pad + flight phase progression

In addition to the foam pad/mat to progress the exercise the therapist can add in perturbations, these could be visual or physical perturbations. Visual perturbations could be advantageous for athletes, as they have to take in a lot of external information whilst remaining focused for their task at hand. The step-up is a very versatile exercise; in that it can be altered to conduct a side step-up (Figure 11), a step-up with an eccentric step down (Figure 12), a weighted step-up (Figures 13 and 14) +/- an eccentric step down

Figure 11: Side step up
Figure 11: Side step up
Figure 12: Eccentric step down
Figure 12: Eccentric step down
Figure 13: Weighted step up
Figure 13: Weighted step up
Figure 14: Weight step up
Figure 14: Weight step up

In summary, from the available research lateral ankle ligament sprains are the most common injury to affect both the general and the athletic populations, with the ATFL is injured most frequently. An increase in pain when placing the ankle into: PF, abduction, and inversion, combined with an increase in pain during the anterior draw test, and pain on palpation over the ATFL is sufficient to point towards an ATFL injury. Although it is very important for the clinician to still think about concurrent injuries: Ottawa ankle rules, Syndesmosis injury, Maisonneuve fracture, Lisfranc injury, 5th metatarsal fracture etc. An acute injury to the ATFL responds well to the P.O.L.I.C.E principle and early mobilisation, and should then be fully assessed 4 days post injury. This early mobilisation will provide the basis for sport specific training i.e. strength and NMC. NMC is one method by which the ankle can be made more stable; and as such reduce the likelihood of recurrent sprains/ankle instability.


Opinions expressed by physiogramworld contributors are their own.


  1. Lynch, S.A. and Renström, P.A.F.H., 1999. Treatment of acute lateral ankle ligament rupture in the athlete: conservative versus surgical treatment. Sports Medicine, 27(1), pp. 61-71.
  2. Tohyama, H., Yasuda, K., Ohkoshi, Y., Beynnon, B.D. and Renström, P.A.F.H., 2003. Anterior drawer test for acute anterior talofibular ligament injuries of the ankle: how much load should be applied during the test? The American Journal of Sports medicine, 31(2), pp. 226-232.
  3. Gutierrez, G.M., Kaminski, T.W. and Douex, A.T., 2009. Neuromuscular control and ankle instability. PM & R: The Journal of Injury, Function, and Rehabilitation, 1(4), pp. 359-365.
  4. Kerkhoffs, G., Van Den Bekerom, M., Elders, L.A.M., Van Beek, P.A., Hullegie, W.A.M, Bloemers, G.M.F.M., De Heus, E.M., Loogman, M.C.M, Rosenbrand, K.C.J.G.M., Kuipers, T., Hoogstraten, J.W.A.P., Dekker, R., Ten Duis, H.J., Van Dijk, C.N., Van Tulder, M.W., Van der Wees, P.J. and De Bie, R.A., 2012. Diagnosis, treatment and prevention of ankle sprains: an evidence-based clinical guideline. British Journal of Sports Medicine, 46(12), pp. 854-860.
  5. Brukner, P. and Khan, K. 2013. Clinical sports medicine. 4th Australia: McGraw-Hill Education.
  6. Gribble, P.A., Bleakley, C.M., Caulfield, B.M., Docherty, C.L., Fourchet, F., Fong, D.T.P., Hertel, J., Hiller, C.E., Kaminski, T.W., McKeon, P.O., Refshauge, K.M., Verhagen, E.A., Vicenzino, B.T., Wikstrom, E.A. and Delahunt, E., 2016a. A 2016 consensus statement of the International Ankle Consortium: Prevalence, impact and long-term consequences of lateral ankle sprains. British Journal of Sports Medicine, 50(24), pp.1493-1495
  7. Gribble, P.A., Bleakley, C.M., Caulfield, B.M., Docherty, C.L., Fourchet, F., Fong, D.T.P., Hertel, J., Hiller, C.E., Kaminski, T.W., McKeon, P.O., Refshauge, K.M., Verhagen, E.A., Vicenzino, B.T., Wikstrom, E.A. and Delahunt, E., 2016b. Evidence review for the 2016 International Ankle Consortium consensus statement on the prevalence, impact and long-term consequences of lateral ankle sprains. British Journal of Sports Medicine, 50(24), pp. 1496-1505
  8. Platzer, W. 2009. Color atlas of human anatomy: Locomotor system. 6th Stuttgart: Thieme.
  9. Sman, A.D., Hiller, C.E., Rae, K., Linklater, J.L., Black, D.A., Nicholson, L.L., Burns, J. Refshauge, K.M., 2013. Diagnostic accuracy of clinical tests for ankle syndesmosis injury. British Journal of Sports Medicine, 47(10), pp. 620-628.
  10. Bachmann, L.M., Kolb, E., Koller, M.T., Steurer, J. and ter Riet, G., 2003. Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review. British Medical Journal, 326(7386), pp. 1-7.
  11. Beckenkamp, P.R., Lin, C.W.C., Macaskill, P., Michaleff, Z.A., Maher, C.G and Moseley, A.M., 2016. Diagnostic accuracy of the Ottawa Ankle and Midfoot Rules: a systematic review with meta-analysis. British Journal of Sports Medicine, Online First, pp. 1-8
  12. Bleakley, C.M., Glasgow, P. and MacAuley, D.C., 2012. PRICE needs updating, should we call the POLICE? British Journal of Sports Medicine, 46(4), pp. 220-221.
  13. Mueller-Wohlfahrt, H.W., Haensel, L., Mithoefer, K., Ekstrand, J., English, B., McNally, S., Orchard, J., Van Dijk, C.N., Kerkhoffs, G.M., Schmasch, P., Blottner, D., Swaerd, L., Goedhart, E. and Ueblacker, P., 2013. Terminology and classification of muscle injuries in sport: The Munich consensus statement. British Journal of Sports Medicine, 47(6), pp. 342-350.
  14. Hossain, M. and Thomas, R., 2015. Ankle instability: presentation and management. Orthopadeics and Trauma, 29(2), pp. 145-151.
  15. Herrington, L., Myer, G. and Horsley, I. 2013. Task based rehabilitation protocol for elite athletes following anterior cruciate ligament reconstruction: a clinical commentary. Physical Therapy in Sport, 14(4), 188-198.
  16. Paterno, M.V., Myer, G.D., Ford, K.R. and Hewett, T.E., 2004. Neuromuscular Training Improves Single-Limb Stability in Young Female Athletes. Journal of Orthopaedic and Sports Physical Therapy, 34(6), pp.305-316.
  17. Coughlan, G. and Caulfield, B., 2007. A 4-week neuromuscular training program and gait patterns at the ankle joint. Journal of Athletic Training, 42(1), pp. 51-59.

How to Expand and Nurture Professional Referrals with other Practitioners

How to Expand and Nurture Professional Referrals with other Practitioners

Want to generate more clients to your clinic?


Typically, Referred clients are more often, better clients. By that, we mean that they buy quicker and with less resistance, they buy more quantity and more frequently and they are more likely to refer more clients (Jay Abraham).

40% Professional Referrals
40% Client Referrals
20% Other Referrals (marketing & advertising)

In this article, we are going to focus on the 40% Professional Referrals.

It’s a relationship!

Nurturing Professional Referrals is all about relationship building. Any relationship is an opportunity to give! If you go into any relationship with the intention to just receive, it’s highly unlikely to thrive. However, when we speak with most practitioners, they all ask, how can I GET more referrals from the Doctors, medical specialists, massage therapists, podiatrists etc?
See how this question relates directly to “how can I receive in this relationship”…?!

As Gary Vaynerchuck says, it’s a “marathon not a sprint”. We are in it for the long run, so our actions need to reflect that. Therefore, let’s look at how we could give value upfront so that we position ourselves as a person of value and worth within their network.

We all do business with people we know, like and trust. Therefore, we need to establish this with our network before we can create a relationship that supports the growth of one another’s clients and clinic’s. How do we do that? We are going to add value to that person/clinic!

We need to position ourselves as someone who can contribute greatly to our networks life by offering them as much value as we can.

Reminder, this is not intended to be manipulative or in any way bribe another person. You’ll never develop a relationship based on transactional thinking like this. Instead, what you need to do is approach the people and businesses you believe have the greatest synergies with you and your client base so that you can work together.

How can I nurture my Network?

We need to provide personalized, upfront value. We do that by understanding everything about the referral practitioner that we can. That means the next 1-3 meetings you have needs to be strongly focused on them. You need to ask them as many questions about their practice, clinic, clients and personal life so that you fully understand who they are.

A quick search on social media and google will also tell you who they are, what they like, how they work etc. Also, you need to find out their needs, wants, and desires in a professional setting. Obviously, you will use your professional discretion about what’s relevant or not, however, like any relationship, we need to understand the person we’re connected with. The deeper that understanding, the greater likability, trust and rapport we can create.

As a guide here are 30 ways to provide value to a referral partner once you know how you could help them…

How to get the most out of this…

We suggest you ask, “How can I tailor this to ‘insert referral practitioner’ so that they get the most value from me. Literally, sit down and write a list before every meeting you have with someone so that you come from a place of giving.

How to create lasting results

The key for any relationship is consistency.

Frequent contact is required to nurture any relationship, so ensure you have a number of channels to stay connected and offer this value e.g. email, phone, social media, messaging apps like slack or WhatsApp, snail mail post etc.

Ensure you are connected and have their details in as many of these avenues as possible. This will allow you to stay top of mind!


You need to actually do it consistently. For consistency, you need three things:

  1. Trigger – a prompt to initiate the activity or use of the system (could be a note in the diary or task manager app like Asana or Wunderlist)
  2. System – a series of sequenced steps to help create the desired outcome (anyone should be able to follow it, it’s like a recipe, it’s replicable)
  3. Tracker – a way to measure if it has been done and/or how effectively the system was implemented/used (could be a table or spreadsheet to report on)

How to nurture existing referral practitioners

  1. Create a list of existing referral practitioners
  2. Reach out to them and offer them 1 piece of ‘value’ each week for 3 weeks
  3. Ask for a meeting on week 4
  4. Repeat

How to Expand into new referral networks

Step One – Create a list

Create a list of other health professionals and businesses you want to connect with that see and serve your ideal client;

  • New practitioners/businesses to the area/suburb/location
  • Practitioners/businesses in a complementary niche/practice/approach to you
  • Practitioners/businesses recommended by current practitioners in your network
  • Popular practitioners/businesses that also see a number of your current clients, ask your clients at every new client consultation who they see.
  • Search location based businesses on facebook, instagram, google e.g. Podiatrist Sydney Surry Hills, or Gym Surry Hills, or Cross fit surry Hills, or Surry Hills f45, or Healthy cafe Surry Hills

Step Two: Connect with them

  • Add and follow them on all social media channels. Do this for both the brand/company/business/clinic and the people behind it on their personal accounts, the owner/director/founder.
  • Find out what they post about and identify what their preferences are. There is a lot you can find out from observing their post behaviours and also what they have written on their profiles in their ‘bio’ section. Use this information to create rapport and connect with mutual interests.
  • For 3 weeks; like, comment and share all of their content. Be really engaged with them and show your support for what they are doing. Ask questions on their posts, reinforce their message, acknowledge the points they make if you agree and tag your friends, colleagues, team members and clients where appropriate.
  • Give them a shout out on your social media posts, tag them in your pictures and in the comments, post about their content and advise your community to follow them because of their content.
  • If you get engagement in return from them, then you can move forward yourself, with the intention to organise a meeting. Always refer back to the 30 ways to give value (table).
    • Give as much value as you can and then Ask for a meeting via direct message on social media or through email.
      • Hi, I’m really enjoying your posts and content. We see a number of clients that could benefit from the work that you do. Would you be able to meet up so that i could find out more about your approach and how i could refer clients to you?
    • If you do not get any engagement from them, then you can seek an introduction from an existing referrer to the new prospective connection (Step Three).

Step Three: Ask for an Introduction

Ask your current Referral connections if they have any connection and if they would introduce you to any of these networks that you have listed.

  • Subject: do you know these guys?
  • Hi ….. Im wondering if you have any connection to XYZ clinic…? If you don’t, then i suggest you check them out and connect with them on (instagram, facebook). I’ve been following them for a couple of weeks and they are producing a lot of interesting content, if nothing else, it’s good to see how they are approaching their marketing and social media. If you do have a connection, that’s awesome, you’ll be able to tell them that we’re on board with what they’re doing! On another note, what’s the best way to reach out to them so that we could connect personally and professionally, maybe in person…. Would you be willing to introduce me via email? Let me know what you think is best, because it would be great to connect.
    • If no, that’s alright, connect your existing referrer with the prospect online by telling them to follow them.
      • Ask your referral Network if they have any really great networks that you should get to know.
      • The more specific you are, the better your results will be
      • g. Hi ….. Im looking to connect with a really good local physiotherapist, or
      • g. Hi …. Im looking to connect with some sports therapists, like physio, podiatry and osteopathy…Do you have anyone that’s doing some great work with clients in this area…? I’d love to connect with them so that i could have somewhere to refer my clients to. I’m just looking to connect with one practitioner, let me know who you’d recommend. Talk soon

What’s in it for you?

At the end of the day, attracting more new clients to your clinic is great for business. However, It’s not the only benefit you can receive from a referral relationship!


You still need to ask for referrals once you have enough credit with the referral partner. The key is to ask intelligently. That means be specific about your ideal client so that they know exactly who to send to you. Don’t say that you treat anyone or everyone… don’t be vanilla ice ice baby!

The other benefits of a strong referral partnership are:

  • Better nurturing and care for existing clients with better communication of the health care team
  • Access one another’s networks to amplify clinic growth through shared connections, either through other practitioners or businesses etc
  • Minimise expenses by combining business doings e.g. buyers group discounts with suppliers, marketing etc
  • Access greater knowledge on health and business with shared resources and trainings
  • Strengthen position in the community because of the collaboration (standout) e.g. co-branding, joint ventures etc

Don’t just think it’s about the transfer of clients, because you may not have most ideal client bases to share, however, you can lead one another to other sources of client generation while experiencing all of these other benefits!

In Summary

Always think about, what is in it for them. Do your best to make their life better and once you have a strong line of communication, ask specifically for their help in building your clientele and network.

To exchange more ideas with your peers on this topic, you are welcome to join the facebook group “Health Professional in Business. Simply request to join, answer the 3 questions before entering and dive into the discussions.

Until next time, continue to consult with passion and serve with care.


Opinions expressed by physiogramworld contributors are their own.


Should You Wait Before Having Surgery for An ACL Tear?

physiogramworld UCL Injury

For some people, delaying knee surgery after an ACL rupture and trying exercise therapy instead may produce better outcomes over the long term, researchers suggest.

Doing surgery on a torn ACL (anterior cruciate ligament) soon after the injury may be linked to worse problems five years later, especially if an individual also has a lot of pain and swelling or has injured other parts of the knee at the same time, lead study author Dr. Stephanie Filbay of the University of Oxford in the UK.

It can lead to a longer recovery and worse prognosis, she told Reuters Health.

Filbay and her colleagues analyzed data from a trial comparing outcomes for 18-to-35 year olds who, within a month of an acute ACL injury, were randomly assigned to surgery plus exercise or exercise therapy alone with the option to have surgery later.

Sixty-two participants had surgery plus exercise therapy and 59 had exercise therapy first. Half of the exercise-first group went on to have surgery: 23 of them about two years after the injury and seven in the three years after that, according to the report in the British Journal of Sports Medicine.

Exercise therapy alone led to fewer knee symptoms compared with early surgery plus exercise therapy, at least in the short term.

Those who had early ACL surgery and also had an injured meniscus (cartilage pad in the knee joint) were less able to participate in sports post-surgery, and those who also had an injured ankle had a worse quality of life after surgery.

On the other hand, those who had exercise therapy alone and went on to have surgery on a different part of the knee had worse pain five years later than those who didn’t have non-ACL surgery.

Taken together, the authors say, the findings suggest that young, active individuals with an acute ACL injury who also have an injured meniscus, and those who have more severe knee pain and functional problems early on may benefit most from starting with exercise therapy first, before considering ACL reconstruction.

However, decisions should be made on a case-by-case basis, they advise.

Dr. Michael Alaia, an orthopedic surgeon at NYU Langone Medical Center in New York, said this study was small and “larger studies will be necessary to truly understand which patients may benefit from an extended trial of non-operative management of their ACL tears.”

While the authors found that some active young people might benefit from an exercise-first approach, Alaia suggests the approach might benefit patients who are less physically active, have other medical conditions or don’t engage in sports requiring pivoting.

“Limiting the number of ‘giving way’ episodes could reduce the chance of further damage to other important structures inside the knee,” he told Reuters Health in an email.

Alaia noted that many of his New York City patients who had no insurance coverage until after implementation of the Affordable Care Act had ACL tears years earlier – as active teenagers or young adults – but could not obtain treatment. “Unfortunately, a great number of these patients went on to develop significant cartilage or meniscus damage at an early age,” he said.

“This highlights the dilemma we have as surgeons – to try and figure out which patients will demonstrate continued instability and who will not,” he said, “and treat them appropriately before they go on to develop irreversible changes.”

Please share your thoughts on comment section.

Source(s): Business Insider, Reuters Health

Opinions expressed by physiogramworld contributors are their own.

Musculoskeletal injuries associated with “underuse” mechanism.

I recently received an e-mail from a supplement company telling me to ‘start my summer prep’, which lead me to think about the stereotypical summer holiday preparation. You have just booked yourself a beach holiday, or a hotel getaway to lounge by the pool, and you begin making preparations: someone to watch the house, someone to look after the cat or dog, you purchase new clothes, and you feel the need to hit the gym to feel more comfortable. Whilst making healthier nutrition choices or becoming more physically active would be sufficient, the subconscious bombardment of the ‘ideal beach bod’ on TV commercials and e- mails such as the one I received, lead people to take up more intense exercise to achieve their goal. This article is going to focus on the injuries associated with the uptake in physical activity (PA) due to an underuse mechanism.

PA has been defined by the National Institute for Health and Care Excellence (NICE) as the full range of human movement, including hobbies such as walking or cycling, and any activities of daily living such as walking up stairs, gardening, or housework.3 PA has been associated with numerous health benefits, such as a reduction in the incidence and mortality associated with: cardiovascular disease, diabetes, obesity, hypertension, and cancer.4,6 As such, there are guidelines published across the world regarding the minimal amount of physical activity that should be achieved by various age groups to attain these associated health benefits.

High levels of physical inactivity are of global concern,7 with many countries

facing an epidemic of physical inactivity8 for example, out of 85 countries, 50%

or less of adolescents achieved the minimum recommendations.9 Physical

inactivity has prompted a rise in diseases (obesity, diabetes etc) and the number

of musculoskeletal injuries (MSKI’s) amongst children and adults.9,10

The World Health Organization (WHO) classifies physical inactivity as the 4th

leading risk factor of global mortality.1 Evidence has shown that those with lower

levels of PA had the strongest association with overall MSKI risk,11,12  with Body

Mass Index (BMI) being significantly associated with injuries of the lower

extremity and the odds of injury increased 6-10% for each unit increase in BMI.5,10,13

Numerous authors have proposed possible mechanisms by which physical inactivity contributes to an increased MSKI risk, some theorized that this was due to low levels of strength and decreased cardiovascular fitness.4,14 Whilst others postulated that increased weight during childhood combined with physical inactivity, affected bone development in load-bearing bones contributing to

skeletal malalignment and/or changes in muscular function.10,13 Essentially, those who were more physically inactive tended to underuse their body.

The idea of the bodies’ susceptibility to injury from underuse is not completely new. As part of a new model for tendinopathies, it was proposed that the underloaded tendon does not receive appropriate physiological stresses; leading to degradation.15 Therefore once the tendon is subjected to activity that is higher in level than that which is normally placed upon it, this will subject the tissues to overload; starting the degenerative cascade of tendinopathies.15 This idea seemed to be a further contribution to the small body of evidence,8 where the authors detail how research typically classifies MSKI’s as ‘acute’ or ‘overuse’ due to reports interpreting that the preceding movement caused a persons MSKI. However the underlying cause for many MSKI’s in a physically inactive population is in fact ‘underuse’; whereby the body is required to move in an unfamiliar method.8

The literature has shown trends that those who are more physically inactive tend to underuse their body, and once they start a period of activity above that which their body is used to, their body cannot adapt and tissues are overloaded causing an injury. Is it then possible to prevent or reduce the likelihood of acquiring an MSKI? In short yes, but how can one go about this?

First lets address previous injuries, so as to start fresh. Previous injuries have been shown to be a significant risk factor for sustaining an injury16,20 due to the incomplete recovery of the earlier injury.18 Research has shown17,19 that those who have had a previous ankle sprain have a 30-50% higher chance of sustaining another ankle sprain, these authors further state that these repetitive injuries are location specific, i.e. a previous ankle injury has the potential to cause another injury to the same ankle.17 So in the lead up to the summer holiday and before beginning any new exercise program, especially if it has been a sufficient time period since the last formalized training period, any previous injuries should be fully rehabilitated. Proper injury rehabilitation can be achieved through a qualified Physiotherapist, Physical Therapist, or an Athletic Trainer

Next up is periodized training; to periodize ones training means to deliberately adjust or manipulate the training volume and intensity over time.21 It is one method of reducing the sudden and abrupt load exerted on the body,22 optimizing performance whilst mitigating injury risk.23 The body has the ability to adapt to any new form of training, however this process takes time,22 as such periodized training is normally formed around macro-, meso- and micro-cycles; ≈ 1-year, ≈ 6-12 weeks, ≈ 1-day respectively.21,23 These cycles allow for greater variety in ones training, changing up the stimuli (types of exercises, reps, sets, rest etc)23,24 received by the body allowing it to adapt, and therefore progress21,23 e.g. to lift a heavier weight, run a longer distance, or run a quicker time. A qualified Sports Physiotherapist, Sports Physical Therapist, Athletic

Trainer or a qualified Strength and Conditioning Coach will be able to assist with training periodization.

The final tip is centred on the warm-up; the multiple benefits of a well-designed warm-up are well known, such as: Injury reduction, faster muscle contraction, increased blood flow and therefore improved oxygen delivery, etc.25-30 Warm- ups will vary dependent on the physical activity about to be undertaken but will generally last 10-30 mins,25 and typically consist of a pulse raiser, stretching and sport specific movements.25-26,31 Warm-ups will typically follow a protocol such as the Raise, Activate and Mobilize, and Potentiate system – aptly named the ‘RAMP’ system.25 Sports governing bodies have listened to the research and recognize the benefits of a well-designed warm-up; as such organizations like Fédération Internationale de Football Association (FIFA), have produced an easy to follow / administer, standardized warm-up: the FIFA 11+.27,30 The research has shown the FIFA 11+ to reduce injuries in young female football players by approximately one third and all severe injuries by half,27 with significantly fewer training and match injuries in amateur players.28

In summary, the MSKI risk is higher in those who are physically inactive, when undertaking PA; due to an underuse mechanism. The evidence has shown that those who are classified as ‘obese’ have a higher MSKI risk than those who are ‘overweight’ or ‘normal weight’, as the risk increased 6-10% for every unit increase in BMI. The greatest risk is for the lower extremities/load bearing bones, which is of particular importance for children and adolescents due to the increased stresses placed on their developing body.

For these more physically inactive populations, while PA may cause the injury, it is due to the underuse of the body. The underuse has led to weakening of the body in general, whereby it cannot cope once the body begins to move in intensities above that which it can handle; especially if in an abnormal pattern. This article provides three simple building blocks to help reduce the likelihood of suffering from an underuse injury in the lead up to the summer. These three building blocks should form questions you should ask yourself prior to starting a new workout or fitness regime, especially after a prolonged period of inactivity or reduced activity:

  • Do I have any injuries I need to sort out first?
  • How am I going to structure my training?
  • What will my warm-up consist of?


  1. World Health Organization, 2010.Global recommendations on physical activity for health. WHO Library Cataloguing-in-Publication Data, pp. 7
  2. National Institute on Aging 2016. Exercise and Physical Activity:Your Everyday Guide. Department of Health and Human Services: National
    Institute on Aging Publication No. 17-AG-4258, pp 18
  3. National Institute for Health and Clinical Excellence,2015. Preventing excessive weight gain. NICE guideline (NG7)
  4. Hootman,J.M., Macera,C.A., Ainsworth,B.E., Addy,C.L., Martin,M. and
    Blair, S.N., 2002. Epidemiology of musculoskeletal injuries among sedentary and physically active adults. Medicine and Science in Sports and Exercise, 34(5), pp. 838-844.
  5. Janney,C.A. and Jakicic,J.M., 2010. The influence of exercise and BMI on injuries and illnesses in overweight and obese individuals: a randomized control trial. International Journal of Behavioral Nutrition and Physical Activity, 7(1), pp. 1-11.
  6. Mendes,R., Sousa,N., Reis,V.M. and Themundo-Barata,J.L., 2016. Prevention of exercise-related injuries and adverse events in patients with type 2 diabetes. Postgraduate Medical Journal, 89(1058), pp. 715-721.
  7. Gray,C., Gibbons,R., Larouche,R., Sandseter,E.B.H., Bienenstock,A., Brussoni, M., Chabot, G., Herrington, S., Janssen, I., Pickett, W., Power, M., Stanger, N., Sampson, M. and Tremblay, M.S., 2015. What Is the Relationship between Outdoor Time and Physical Activity, Sedentary Behaviour, and Physical Fitness in Children? A Systematic Review. International Journal of Environmental Research and Public Health, 12(6), pp. 6455-6474.
  8. Stovitz,S.D. and Johnson,R.J., 2006.“Underuse” as a cause for musculoskeletal injuries: is it time that we started reframing our message? British Journal of Sports Medicine, 40(9), pp.738-739
  9. Draper,C.E., Grobler,L., Micklesfield,L.K. and Norris,S.A., 2015. Impact of social norms and social support on diet, physical activity and sedentary behaviour of adolescents: a scoping review. Child: Care, Health and Development, 41(5), pp. 654-667.
  10. Shultz, S.P., Anner, J. and Hills, A.P., 2009. Paediatric obesity, physical activity and the musculoskeletal system. Obesity Reviews, 10(5), pp. 576- 582.
  11. Nauta, J., Martin-Diener, E., Martin, B.W., van Mechelen, W. and Verhagen, E., 2015. Injury risk during different physical activity behaviours in children: a systematic review with bias assessment. Sports Medicine, 45(3), pp. 327-336.
  12. Bloemers, F., Collard, D., A Paw, M.C., van Mechelen, W., Twisk, J. and Verhagen, E., 2012. Physical inactivity is a risk factor for physical activity-

related injuries in children. British Journal of Sports Medicine, 46(9), pp.

13.Adams, A.L., Kessler, J.I., Deramerian, K., Smith, N., Black, H.B., Porter,

A.H., Jacobsen, S.J. and Koebnick, C., 2013. Associations between childhood obesity and upper and lower extremity injuries. Injury Prevention, 19(3), pp. 191-197.

  1. Trudelle-Jackson, E., Jackson, A.W. and Morrow, J.R., 2011. Relations of meeting national public health recommendations for muscular strengthening activities with strength, body composition, and obesity: the women’s injury study. American Journal of Public Health, 101(10), pp. 1930-1935.
  2. Lewis, J.S., 2010. Rotator cuff tendinopathy: a model for the continuum of pathology and related management. British Journal of Sports Medicine, 44(13), pp. 918-923.
  3. Opar, D.A., Williams, M.D. and Shield, A.J., 2012. Hamstring strain injuries: Factors that lead to injury and re-injury. Sports Medicine, 42(3), pp. 209-226.
  4. Zambraski, E.J. and Yancosek, K.E., 2012. Prevention and rehabilitation of musculoskeletal injuries during military operations and training. Journal of Strength and Conditioning Research, 26(7), pp. S101-S106.
  5. Jacobsson, J., Timpka, T., Kowalski, J., Nilsson, S., Ekberg, J., Dahlström, Ö. And Renström, P.A., 2013. Injury patterns in Swedish elite athletics: annual incidence, injury types and risk factors. British Journal of Sports Medicine, 47(15), pp.1-13.
  6. Fulton, J., Wright, K., Kelly, M., Zebrosky, B., Zanis, M., Drvol, C. and Butler, R., 2014. Injury risk is altered by previous injury: A systematic review of literature and presentation of causative neuromuscular factors. The International Journal of Sports Physical Therapy, 9(5), pp. 583-595.
  7. Saragiotto, B.T., Yamato, T.P., Hespanhol Junior, L.C., Rainbow, M.J., Davis, I.S. and Lopes, A.D., 2014. What are the main risk factors for running-related injuries? Sports Medicine, 44(8), pp.1153-1163.
  8. Nindl, B.C., 2015. Physical training strategies for military women’s performance optimization in combat-centric occupations. Journal of Strength and Conditioning Research, 29(11S), pp. S101-S106.
  9. Sharma, J., Greeves, J.P., Byers, M., Bennett, A.N. and Spears, I.R., 2015. Musculoskeletal injuries in British Army recruits: a prospective study of diagnosis-specific incidence and rehabilitation times. BMC Musculoskeletal Disorders, 16(106), pp. 1-7.
  10. Kraemer, W.J. and Szivak, T.K., 2012. Strength training for the warfighter. Journal of Strength and Conditioning Research, 26(7), pp. S107-S118.
  11. Lauersen, J.B., Bertelsen, D.M. Andersen, L.B., 2014. The effectiveness of exercise interventions to prevent sports injuries: A systematic review and meta-analysis of randomised controlled trials. British Journal of Sports Medicine, 48, pp.871-877.
  12. Jeffreys, I., 2007. Warm up revisited – the “ramp” method of optimising performance preparation. Professional Strength and Conditioning, 6, pp.15-19.
  13. Woods, K., Bishop, P. and Jones, E., 2007. Warm-Up and Stretching in the Prevention of Muscular Injury. Sports Medicine, 37(12), pp. 1089- 1087.
  14. Soligard, T., Mykleburst, G., Steffen, K., Holme, I., Silvers, H., Bizzini, M., Junge, A., Dvorak, J., Bahr, R. and Anderson, T.E., 2008. Comprehensive warm-up programme to prevent injuries in young female footballers: clustered randomised controlled trial. British Medical Journal, 9(337), pp. 1-9.
  15. Junge, a., Lamprecht, M., Stamm, H., Hasler, H., Bizzini, M., Tschopp, M., Reuter, H., Pshch, D., Wyss, H., Chilvers, C. and Dvorak, J., 2010. Coutnrywide campaign to prevent soccer injuries in Swiss amateur players. The American Journal of Sports Medicine, 39(1), pp. 1-7.
  16. Soligard, T., Nilstad, A., Steffen, K., Mykleburst, G., Holme, I., Dvorak, J., Bahr, R. and Andersen, T.E., 2010. Complience with a comprehensive warm-up programme to prevent injuries in youth football.
  17. Herman, K., Barton, C., Malliaras, P. and Morrissey, D., 2012. The effectiveness of neuromuscular warm-up strategies, that require no additional equipment, for preventing lower limb injuries during sports participation: a systematic review. BMC Medicine, 10(75), pp. 1-12.
  18. Fletcher, I.M. and Jones, B., 2004. The effect of different warm-up stretch protocols on 20 meter sprint performance in trained rugby union players. Journal of Strength and Conditioning Research, 18(4), pp. 885-888.

Opinions expressed by physiogramworld contributors are their own.

Scientific Evidence indicates beneficial adaptations of Inter-vertebral Disc in fast walkers and slow runners.

New research findings indicate that running exercise may be good for your intervertebral discs (IVDs) which counters previous assumptions that running impact may cause extra pressure and harm to the spine.

This new evidence, the first ever cross-sectional study in humans, suggests that favorable tissue adaptation -hydration and proteoglycan content, hypertrophy- was associated with chronic running exercise in men and women.

The researchers recruited runners aged 25-34 with a minimum of five years history at their current physical activity level: either no sports (referents), 20-40 km per week running (joggers), or 50+ km per week running (long-distance runners). It was noted that discs were better hydrated in long- distance runners and joggers compared to non-athletic individuals. Also, IVD hypertrophy at the lower lumbar levels was greater in long-distance runners, but only a little, this suggests tissue adaptation to habitual loading will occur in the IVD with exercises, in relation to hypertrophic changes seen in muscles after resistance training. Furthermore, additional data from 10 runners noted adaptation were strongly associated with activities such as fast walking and slow running as opposed to fast running and high impact jumping considered to be harmful to the IVD. No beneficial adaptations of IVD was noted in sedentary activities and possibly not required for high intensity running.

In summary, running exercise can be beneficial for the Intervertebral disc and specific exercise protocols may improve spine characteristics.

Get to Running!

5 Ways to Stand out as a #DPTStudent

A few weeks ago in group mentorship program Erica Meloe, PT and I oversee (PTIQ), one of the DPT students asked the question: How can I stand out as a DPT student? This is something I think everyone can relate to regardless of whether you are a student, new grad or seasoned veteran. For this post I am going to concentrate on what it takes to set yourself apart from the pack as a #DPTStudent. (Perhaps more posts to follow about standing out as a new grad and as a seasoned vet.)

  1. Be active on social media. 

It is one thing to have social media accounts but it is a far different thing to be active on those accounts. If you want to be known and make an impact  as a student then you must take action! This does not mean that you have to spend hours a day on social media (you have tests to take and studying to do after all) but try to dedicate some time each week. For the most part social media is a fairly even playing field and we all have something to contribute!   My tips for getting noticed online are:

  • Join Facebook groups such as the Doctor of Physical Therapy Students group. Then jump into a conversation, start a discussion or ask questions. Not only are there tons of students in the group but there are also seasoned PTs there who have been in your shoes once and want to help!
  • Join Twitter! If you are on Twitter reach out to PTs you admire and don’t be afraid to jump in on a conversation. That is the best way to gain more followers and interact with PTs from all over the world. Also, be sure to join in on Tweet Chats. The APTA Student Assembly has regular tweet chats with hashtag #XchangeSA
  • Have an updated LinkedIn page! Do not neglect LinkedIn. This is THE professional social media platform. Just because you are a student does not mean you don’t have life and work experience. This should all be on your profile along with a clear professional looking picture. Make sure you keep updating your LinkedIn profile after each semester, clinical rotation, cont ed course, etc. This is where potential employers are looking for that one perfect candidate….and it might be you!
  • Video is all the rage at the moment. So consider joining Periscope or broadcasting some Facebook Live posts. Think about the valuable content you have to share. Maybe you had an experience in class or at a clinical rotation that you think others can learn from. If so get it out there to the world!
  1. Pitch yourself to a PT related podcast (there are tons of them).

Not sure how to do that…it is pretty simple. Send an email to the host in the following format:

  • Tell the host how much you liked one or more of their podcasts. This shows that you actually do listen to the podcasts and you know what the show is about. And it makes the host feel pretty good!
  • Talk a little bit about yourself (no more than 3-4 sentences). Mention where you go to school, what year you are, any major achievements in life or in school and why you want to become a PT
  • List at least 2-3 topics you would like to talk about on the podcast and why.
  • Be sure to list your contact information including all of your social media outlets.
  • Finally thank the host for their time.
  • If you have not heard back from the podcast host in a week or so send a friendly follow up email.

Don’t forget that everyone has a unique experience, story or outlook that the world is waiting to hear!

  1. Start blogging!

You don’t have to start your own blog as that can be quite time consuming, but you can pitch your blog ideas (to be a guest blogger) to existing blogs by following the steps outlined in pitching a podcast. The main different here is you might want to include some samples of your writing so the blogger gets an idea of your style and can then decide if you would be a fit for their blog.

  1. Take continuing education courses as a student.

I know what you are thinking…that is expensive and I am already paying so much for school I can’t imagine spending more money! But, what if I told you there is a way you might be able to take courses for free or at a very discounted rate. That would get your attention right?   I suggest the “give to get model” and this is how you do it:

  • Get clear on what your interests really are
  • Take a look at your curriculum and seek out continuing education courses that might fill in the gaps in your education
  • Make a list of potential courses
  • Contact the speakers or organizations that run the courses you are really interested in and ask them if they need volunteers to help the course run smoothly. Offer to check people in, set up/clean up before and after the course, help with audio/visual needs, assist the speaker with whatever they need, etc. in exchange for attending the course for free or a highly discounted rate.

Will this approach work every time? Probably not…. but if you never ask the question the answer will always be no!

Not only does this show that you are interested in furthering your education but it also shows that you are a go getter and are not afraid to take action!

  1. Become a student member of the APTA and get involved in the Student Assembly.

This is something I wish I did when I was a student and I really regret not doing so.  Being a student member of the APTA has lots of perks like discounts on continuing education and large conferences. And if you can swing it I highly recommend going to the larger conferences like CSM and NEXT. You will meet tons of PTs, join in conversations outside of the formal classes (this is where all the best convo happen anyway) and you can meet your social media pals in real life. Again, I know this is an expense but I think it is well worth it if you want to be known as a standout #DPTStudent.

Most of the actions on this list are free and will only cost you a few hours a week. So now what?? It is time to take action!!  This week I would love for you to action on one of the following suggestions below.

*If you are not on social media get on it!   If you are, start being more social!

*Make a list of podcasts and/or blogs you would like to contribute to.

*Write out your email pitch for podcasts and blogs (be sure to include all of your credentials).

*Get clear on what aspects of the physical therapy world you are most interested in and compile a list of continuing education courses that appeal to you!

I am sure there are a number of other ways you can stand out as a #DPTStudent. If you have any suggestions I would love to hear them. Please leave them in the comment section below. Or you can find me on Twitter here and on Facebook here. Let’s keep the conversation going!

Have a great week!



P.S. Don’t forget to subscribe to the podcast on iTunes!  And I would be ever so grateful if you left a rating and a review here.

Opinions expressed by physiogramworld contributors are their own.

Why You Should Not Get An MRI For Low Back Pain

Chances are, you’ve had Low Back Pain before. You know how debilitating it can be. When it strikes, one of the first thoughts that go through your head is “is this normal?” The severity of the pain tells you it can’t be normal to feel this way. Thoughts begin to spin through your head – “What did I do to myself? Did I tear something? Do I have a bulging disc? Do I need to get an MRI to find out what’s wrong with me?”
My answer: NO.
Let me explain…

Although it’s not “normal” to have severe pain in your low back, it is common – very common.
Low back pain affects up to two-thirds of adults at some point in their lifetime in industrialized countries.1 You’re not alone. Hopefully that gives you some peace of mind, but you still want to know what’s wrong, don’t you? You want the MRI. Knowing exactly what is causing your pain would give you true peace of mind, wouldn’t it…?

Not so fast.

A recent systematic review2 of 33 articles looked at MRI findings of 3110 asymptomatic individuals – people without pain. The results show that degenerative changes in the lumbar spine are commonly seen in MRI findings of pain-free individuals as well as those with low back pain.
Specific MRI findings in pain-free individuals showed:
• Disc degeneration in 37% of 20-year-olds and 96% of 80-year-olds
• Disc bulge in 30% of 20-year-olds and 84% of 80-year-olds
• Disc protrusion in 29% of 20-year-olds and 43% of 80-year-olds
• Annular fissures in 19% of 20-year-olds and 29% of 80-year-olds

Again, these are MRI findings in people WITHOUT PAIN – disc degeneration, disc bulges, disc protrusions, and annular fissures (tears in the discs).
What do these findings tell us? Is the result shown on the MRI report actually the impairment that is causing your current pain? Was it there before your pain began? It’s impossible to know for sure.

An MRI is likely to show degenerative changes whether you have pain or not. Therefore the MRI leaves you no better off than you were before – still in pain and still not knowing why.

Even if you do get an MRI, then what? Surgery? Unless it’s an emergency, surgery is always the last option in my book, especially when it comes to the spine.

An MRI Can Increase Your Fear and Cause Pain Catastrophizing

Another reason you shouldn’t have an MRI for low back pain is that it can cause you to dwell on the findings and catastrophize the pain.
Imagine you have moderate low back pain, you get an MRI and the report says there is a tear.
“A tear?! That sounds awful! Do I need surgery?”
Every time you experience low back pain in the future, your mind will always go back to the ‘tear’ in your back. But, in radiology reports, the term ‘tear’ often refers to degeneration and often benign conditions related to the aging process.3

The mind is a powerful thing. If given harmful information, it will spin it to create a worst-case scenario for you and your back, potentially leading to poorer outcomes.

An Open Request To Radiologists Everywhere
As we’ve seen, words are powerful. Why not put a disclaimer on every MRI report for low back pain? Like this:

This photo was taken by Matthew Currier. The comment was proposed and written by McCullough, et. al.4
This comment gives people a fair understanding of the situation. The majority of people in the US do not understand medical jargon and would benefit from a comment on an imaging report such as this.

A Better Option For Low Back Pain: Physical Therapy
If you have low back pain, my recommendation would be to forego the MRI and see a Physical Therapist first. A Physical Therapist will perform an evaluation to determine what functional impairments you have that may be contributing to your low back pain. She can also give you treatment, likely including exercises to start performing immediately to address your specific impairments.

Whether you’re currently experiencing low back pain, you’ve had low back pain in the past, or you’re incredibly lucky, there are steps you can take today to prevent low back pain in your future.
For information regarding prevention of low back pain, please see How To Prevent Low Back Pain: 3 Physical Therapy Tips.

In Case Of Emergency
I am not a surgeon. I don’t order MRIs for patients. I am merely stating my opinion that it won’t benefit you to have an MRI for low back pain… unless…

There are instances where low back pain can be an emergency:
• If you have sudden bowel/bladder incontinence or worsening weakness in the legs. These symptoms could indicate nerve damage or cauda equina syndrome.
• If you have severe, continuous abdominal and back pain, which could mean an abdominal aortic aneurysm.

If you are experiencing either of these sets of symptoms, go to the emergency room immediately.
Yes, in case of an emergency, an MRI can be helpful, of course.
When else should you have an MRI for low back pain?
In my opinion, an MRI may be appropriate once all other conservative forms of treatment have failed after an appropriate amount of time. In this case, continued moderate-to-severe low back pain might warrant a closer look to see if something is potentially structurally causing your pain.
How much time? I would say >6 months. This amount of time allows acute and sub-acute phases of normal tissue healing to take place. After the 3-month mark, it is now considered chronic pain
(please take a look at a previous article explaining how chronic pain works).

If it were me, at the 3-month point I would request to see a Physical Therapist who specializes in chronic pain. If 3 months of specialized treatment for chronic pain and pain management again fails, then I would potentially go for the MRI.
When I say treatment “failed”, I mean the pain is still un-manageable and you are unable to find relief. I am assuming you gave therapy 100% of your effort and were compliant with your home exercise program.

In order for you to find success with Physical Therapy, there must be a complete and total buy-in on your part, meaning you are committed to the process day in and day out.
Final Thoughts
An MRI may seem like a routine process to undergo for someone with low back pain – and in today’s healthcare system, it is. This is a problem. As I’ve explained, a lumbar MRI shows degenerative changes in people with or without pain. An MRI can also cause fear and pain catastrophizing.

Too many people are relying on opioids and surgery to relieve pain in this country. People want answers and they want a quick fix regardless of the consequences. I propose a better alternative. Physical Therapy is a non-invasive approach to treatment of low back pain with proven, evidence-based, lasting results.

Get Physical Therapy first!

Question: What are your thoughts? You can leave a comment

Opinions expressed by physiogramworld contributors are their own.

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1 Jarvik JG, Deyo RA. “Diagnostic evaluation of low back pain withemphasis on imaging.” Ann Intern Med 2002;137:586–97 ↩
2 Brinjikji, et. al. “Systematic Literature Review of Imaging Features of SpinalDegeneration in Asymptomatic Populations.” AJNR Am J Neuroradiolv 2015; 1-6 ↩
3 Bossen, et al. “Does Rewording MRI Reports Improve Patient Understandingand Emotional Response to a Clinical Report?” Clinical Orthopaedics and Related Research. Volume 471, Number 11, November 2013
4 McCullough, Brendan J. et al. “Lumbar MR Imaging and Reporting Epidemiology: Do Epidemiologic Data in Reports Affect Clinical Management?” Radiology 262.3 (2012): 941–946. PMC. Web. 13 Jan. 2017.


Integrating Research Into Clinical Practice: How & Why You Should Start Now

As many of you already know, and for others this may be your first time seeing this, the current APTA (American Physical Therapy Association) mission statement reads; “Transforming society by optimizing movement to improve the human experience.”

Have you ever taken a minute to consider what the phrase “optimizing movement” truly means? This is a statement we discussed while developing our platform and forming our purpose, as we believe it is the essence of what we are hoping to communicate to everyone. After multiple conversations, we came to the conclusion that “optimizing movement” is a product of ensuring evidence-based movement, which in itself is a product of remaining immersed in the latest research.

In today’s world, it is a fact that time will always be a barrier to remaining up-to-date with the current evidence. The idea of reading through a 10 page article and performing a literature appraisal for validation after a full day’s work does not bode too well with increased patient demands, productivity standards, and actually having a life (let’s be real now). Attempt that every day, for a few weeks, on top of all your other priorities and responsibilities and we are sure you will be burnt out before you know it. Nonetheless, if we are to be evidence-based practicing clinicians, staying immersed in the research is absolutely essential.
As you will recall, the three pillars of evidence-based practice include professional (or clinical) expertise, patient values and experiences, as well as BEST RESEARCH EVIDENCE.


The question you may ask yourself is, “Well, how do I stay updated with the research despite my time constraints?” If so, that is where we hope to step in for the benefit of your patients, practice, as well as professional development. Each week we will take the time to dissect and repackage the latest available evidence into a format that is engaging and efficient for you to utilize at your convenience. It is as easy as a 2 minute read and 1 minute video per week, something that you can do on your lunch break or while you thumb through social media in your down time. Now you may be asking yourself, “Why is this important to me and/or why should I care?” Our response to you is; we ALL as Physical Therapists (and as healthcare providers) have a responsibility to constantly raise the standard of care for our patients. In fact, when looking at the APTA’s core values, various examples of staying immersed in the literature exist such as “assuming responsibility for learning and change”, “pursuing new evidence to expand one’s knowledge” and/or “engaging in the acquisition of knowledge throughout one’s professional career.”

At the end of the day, if we are to truly embrace being evidence-based practicing clinicians, the way we view research as a whole NEEDS to change NOW! As opposed to looking at the literature as antiquated and clunky (credit to our friend Dr. Teddy Willsey), we NEED to adopt the mindset that strives for lifelong learning. A mindset that attempts to gain new perspective and question existing paradigms to ultimately ensure that our patients are receiving the highest quality of care possible.

Opinions expressed by physiogramworld contributors are their own.