Musculoskeletal Management and Rehabilitation
Active first, passive adjunct
Rehabilitation is dose-dependent. Name the FITT-VP variables explicitly - frequency, intensity, time, type, volume, progression - and define intensity for resistance work as %1RM or RPE, and for aerobic work as %HRmax or RPE. Tissue specificity matters: tendons respond to slow, heavy loading; muscle to progressive overload; bone to impact and directional loading. Education and reassurance are active ingredients, not placebos.
Core concepts
- Loading progression: start below the symptom-provoking load and progress volume by roughly 5–10% per week as tolerated.
- Pain-monitoring model: mild pain during exercise (up to 3/10) that settles within 24 hours and does not progressively increase is acceptable.
- Osteoarthritis: exercise, education and weight management are first-line; arthroscopy is not indicated for degenerative meniscal tears.
- Adherence: specific goals, self-monitoring, action planning and removing barriers outperform generic encouragement.
- Return to function: criteria-based (strength symmetry, load tolerance, confidence), not time alone.
Traps
Prescribing rest as a default; substituting passive modalities for loading; vague dosage such as advising the patient to do some exercises; progressing too fast after a flare; and the false dichotomy of pain-free-only versus no-pain-no-gain.
Worked example
Midportion Achilles tendinopathy: heavy slow resistance, 3–4 sets of 6–8 repetitions with a 3-second lift and 3-second lower, two to three times weekly, plus a daily heel-raise programme, reviewed at four weeks. Progress load when 24-hour symptoms are stable. Warn the patient that meaningful change usually takes at least 12 weeks.