It’s Cool to Collaborate


I’ve been thinking, dangerous I know and I wanted to share some of my musings. We all come across various professionals in healthcare and often a good many. Many are memorable, hopefully for the right reasons but occasionally someone really stands out.

For me, my standout colleagues are ones I have collaborated with. I like the Cambridge dictionary definition of collaboration who say it is, ‘to work with someone else for a special purpose.’

My collaboration with Phil Adds, Clinical Anatomist started with my request for an image of the quads on a cadaver! When he responded with enthusiasm that he had many images as it was an area of particular interest this pricked my curiosity. A few coffees later we had hatched a research plan. What was so perfect was he was leading on the anatomy, and I was leading on the clinical questions. A truly perfect collaboration. Neither could do it without the other. This collaboration started in 2007 and continues to this day.

Last year there was a similar moment for Dr Claire Minshull and I. It was evident we were both passionate about knees, exercise and patient -focused care. We were both mad keen on empowering our course delegates and both keen to learn more. So, the obvious thing once again was to collaborate. Claire and I (you have to give us a bonus point for both being called Claire) spent last year writing and in November delivering, The PFJ: From Pain to Performance, our one-day course. After a lot of laughter our first draft was about four days long! After all, Claire wanted all her exercise pearls in there, and I wanted all my clinical pearls in there. So we set to work, learning masses off each other and interweaved our knowledge to come up with a course that hit another mutual passion, clinical applicability. Could I have written this course without her. No way! Could she have done this particular course without me-probably not. Once again, a result of a brilliant collaboration.

So my top tips on collaborating-keep your ears and eyes open to opportunities you could create. Just because it hasn’t been done before doesn’t mean it won’t be amazing.


The PFJ:  From Pain to Performance. Next at Leeds Beckett University on 27th April, 2024.



Here are my various podcasts recorded over the years!

Physiotutors. Discussing Hoffa’s Fat Pad with Claire Robertson | Physiotutors Podcast Ep. 003

Sports therapy Association.:

Focus on The Knee Pt2: ‘Patellofemoral Pain and Fat Pad Syndrome’ with guest Claire Robertson

 Patellofemoral Pain Syndrome Masterclass | Physiotutors Podcast ep.037

Discussing PFP with Claire Robertson | Pint-Sized Podcast Roundup

Physio Matters Session 98 – From Evidence to Practice via the Patella with Claire Robertson

Jacked Athlete Podcast #56: Patellofemoral Pain and Hoffa’s Fat Pad with Claire Robertson

#57 – Patellofemoral pain – an update on the latest literature with Claire Patella

5 Simple Ways to Preventing Knee Pain-Guest Blog by Dr Scott Gray

Most people realize they are ageing when they first experience knee pain. But it’s not just ageing weak bones that cause knee pain. It can happen to anyone regardless of their age.

Anything from an exercise injury to bad fitting shoes can be the cause of your knee pain. To treat your knee pain, it is necessary to understand the cause behind it and make sure the steps you take do not aggravate your condition.

This article will guide you through 5 simple ways that can help you deal with knee pain in the most effective way – that is by preventing it.

As with any medical issue, prevention is always better than a cure. Keeping yourself healthy will be helpful in treating any unexpected injury as well.

Let us start by understanding what all the things that can cause knee pain are.

  • Inflammation caused by acute overloading of knee joints like sudden increase in volume of running.
  • Knee injury from accidents
  • Poor muscle strength
  • This condition puts a lot of weight on the knees and makes them more likely to become inflamed.
  • Bad shoes, bad posture and form during daily activities and during exercise.
  • Exercise injuries that happen due to a lack of stretching and proper preparation.
  • Structural knee problems like arthritis, damaged ligaments, and cartilage tears.

Ways to Prevent Knee Pain

A lot of the above causes can be easily dealt with proper preventive measures. A few lifestyle changes and mindful practices can help you from having to endure the sufferings of knee pain. Here are a few tips:

Strengthen your muscles

Exercise strength-building exercises and try to increase your flexibility. When your muscles are weak, your knee ends up bearing all the weight of your upper body and has less dynamic support.

By following a muscle strengthening exercise routine you can greatly improve your overall flexibility and muscle strength.

Also, make sure you always warm-up before getting into any physical activity.

Here is how you can do some exercises and stretches to help your knee perform well.

  • Perform step-ups on each leg alternating. Simply stand next to a stair and step on it with your body balanced by one leg. Then step back and perform the same with the other leg. You can do this simple routine every day. Don’t do this if you have knee cap pain.
  • Hamstring curls can help stretch and strengthen your hamstrings. Lie flat on your stomach and bend your legs up and down, alternating each leg. You can use resistance band around the ankle if this feels too easy.
  • Butterfly stretch targets your groin and inner thigh muscles. Just sit straight with the soles of your feet pressed together. Hold your feet and lean towards the ground with your back straight. Try holding the stretch for 30 seconds.
  • Exercises like planks and back extensions can help you strengthen your core muscles in the abdomen and lower back area.
  • Swimming can be a good exercise to keep your body fit and be gentle on your joints.

Build up the intensity of your exercises gradually. Don’t perform high-intensity routines right on the get-go. Always warm-up before you indulge in any kind of intense physical activity be it dancing, running or your favourite hockey game.

Maintain a healthy weight

It is a known fact that people suffering from obesity are at a higher risk of developing arthritis and joint pains. All the extra pounds of weight adds in a lot of stress to your knee joints as they are the points where your entire body is balanced upon while standing, walking, running and performing most physical activities. It is also now understood that, just like arteries, the knee joint will be more inflamed if you are heavier.

You can lose about 20 percent of knee pain if you can lose 10 pounds of weight. Losing weight combined with proper muscle strengthening exercises can go a long way in preventing and dealing with knee pain.

Wear good shoes

Good shoes do take you to good places. At least a lot less to the medic, given how much they can impact the health of your knees and feet.

Badly fitting shoes can cause you to move differently and affect your balance.

  • Make sure your shoes are comfortable and supportive.
  • Avoid wearing high heels. High heels put a lot of pressure on your knees as the weight is shifted towards your quadriceps. High heels can force your knees to work double their capabilities. They can also cause low back pain.
  • You should also make sure your exercise shoes are good enough to support the rigorous workout you will be taking on. If you are an avid runner, take time and money to invest in proper fitting running shoes. Try and go to a shop selling a wide variety of shoes with knowledgeable

Take care of strains

Accidents can happen to anyone and knee injuries can be quite common when you accidentally fall down or lose balance when lifting something heavy. The first thing you should do is try to reduce the inflammation around the injury. You can try using ice as first aid.

Do not forego consulting a physician or physical therapist when you suffer an injury. Home remedies are good and fine but if you suffer an injury, make sure it gets addressed in a professional manner.

If you are already experiencing knee pain, consult with a qualified physical therapist on the appropriate workout routines.

Love your knees as they are going to be part of your life for a long time. Stay healthy and stay pain-free.


About the Author: Dr. Scott Gray is a Doctor of Physical Therapy and specializes in back and neck pain relief and sports rehabilitation with his renowned Gray Method treatment by fixing the source of the problem. He owns BIM Sport & Spine Physical Therapy (physical therapy clinic for orthopedic, sport, and spine injuries) and BIM Fitness & Performance (SW Florida’s premier personal training studio and sports performance training facility)

Reflections on 10 years as a working Mum

It is now a decade since I made the decision to be a working Mum and I get asked about this surprisingly often. ‘Does it work?’ ‘Do I feel guilty?’ ‘How many hours?’ etc etc. I thought I would put my thoughts down on paper, and at best encourage other women and men to view the benefits.

When I had my first child my husband supported me brilliantly and essentially said, ‘do what you feel is right’ about going back to work. At that time I was employed in the academic sector and self-employed clinically. There seemed to be so many options; return full-time, just one job and if so which, or reduced hours for both, (if I could negotiate this), or be a stay at home Mum. What on Earth was going to be the right thing to do? I wanted to see my child, but I wanted to maintain my professional identity, I wanted to earn money but surely that would just go on child care?!

Looking back I had a couple of defining moments, both unintentionally provided by my NCT group. The first was the deafening silence that met my comment at 3 months postpartum, ‘that I was missing work’. This made me realised my work was perhaps more important to me than others viewed theirs. The second was the puree party I was invited to when the said babies were six months old. Yes, you read that correctly, a puree party! That was it, I felt I had sunk to a new depth of loss of identity and a position so far removed form what made me happy, I knew I had to go back to work.

The financial side of working at that stage was utterly galling. It felt like every bean earnt was going on childcare. However, (and this is so important) the money spent kept me visible, current and I would not be in the position I am now if I hadn’t made that sacrifice then. Sheryl Sandberg talks abut this in her book, Lean In. The money spent then is earnt back down the line. It is hard, and takes faith in what you are doing, but certainly for me it has paid off.

Being a working Mum has made me ruthless with my time. My own Mum jokes about my ‘twenty-minute slots’. My time management is key and I never go anywhere without a paper to read in case I end up waiting…with an unexpected twenty minute slot. I’ve also discovered the time of day before the rest of the house is up. A little moment of calm to think clearly before the frenetic family/work day starts.

I am most definitely more creative with my work then previously, enjoying the perks of digital working that my former self would never have embraced. To be able to work when the children are in bed, or in a tennis lesson/dance class etc has provided opportunities that has made my educational audience more global. Women have the opportunity to have more flexible working through the digital age, but interestingly research shows it is more men that are embracing that opportunity.

What about the children I hear you ask? Well, there have been some really difficult clashes. Scheduling my course so far in advance means that inevitably clashes happen form time to time. It can be upsetting and probably is the worst aspect for me of working. I actually shed a tear when I realised I was teaching in Ipswich when my sons choir had been invited to sing in Henry VIIII’s chapel at Hampton Court Palace. Could I get from Ipswich to Surrey in half an hour? Of course not. Could I cancel the course and let all the delegates down and risk repetitional suicide-of course not! However, there is an up side to not being able to attend everything. When school and co-curricular timetables are published I ask the children which matches/concerts etc are most important to them for me to attend, and those are prioritised. The children don’t take my presence at events for granted. It makes them special and exciting for them.

The other side-effect of our family choice is that the children are expected to help out-quite frankly they have to. They routinely help empty the dishwasher, hang washing out and also cook. They are practical, helpful children that know that they have to do their bit and I am sure this will serve them well in the future.

As a parent to a boy and a girl I’m further interested by their view of women. I hope I’m setting a great role model to my 8 year old girl that you can have a career and a happy family life and that the back bone of this is hard work. For my son I hope he will respect women and their career choices as he gets older. I do however have to recall when he was five and I was telling him about a conference audience of 1000 delegates I was talking to and he paused then said, ‘ Wow Mummy will you be on a coin next?’ That taught me for talking myself up!!

I can’t confess its been a smooth ride. What I do know is I’m a calmer Mum for not being with the children 24/7. I also feel very strongly it is a very individual choice, and it’s what works for each family that’s important. In the physiotherapy post-graduate lecturing world it is so male dominated. So I say to all those clever, caring and interesting women out there who are debating whether to have a go-believe in yourself and go for it!

36 year old lady with a 9 month old baby, bilateral knee pain.

Running woman with baby stroller enjoying summer day in park. Jogging or power walking supermom, active family with baby jogger.



36-year-old presents with bilateral ache of a vague distribution anteriorly. No Giving way, swelling or locking.




Age and the fact it’s bilateral make it unlikely to be tibiofemoral and more likely to be PFJ.


Aggravating Factors;


Runs >1mile and worsens to 3 miles where she stops as worried about the pain. It then lasts for a few hours but not into the next day.

Kneeling at baby’s bath time and crouching to play with baby immediately painful.

Stair descent painful, ascent fine.

Clutch on new car painful.




This is more mechanical than inflammatory as the pain is identifiably aggravated by certain activities and does not last into the next day. ‘Runners knee’ nickname for PFP as it is a stressor to the PFJ’s. Kneeling and crouching also stressors to the PFJ through direct pressure with kneeling, and compression through quads being end of range for kneeling and crouching.

Stair descent pain classical for PFJ problems.

Clutch in new car-how much driving is she doing, and can we alter ergonomic set up?




Immediate with extension both NWB and WB.




Again, sounding very much like PFJ. Unlikely to be eased by extension if it was infrapatellar fat pad.




Regularly exercised x4 a week, including x2 10km runs until pregnancy. Tricky pregnancy with lots of sickness, followed by C section means she has not exercised for last 18 months. Stopped gym membership, ‘waste of money’, and trying to run x1 a week at weekend when she is ‘going for it’ as it’s her only real exercise. Misses the social interactions of exercise classes she used to do at the gym.

She was an events manager, ‘always on her feet’. She has stopped work as the hours are too long.

She is doing more day-to day driving trying to get out and about with new baby.

Insidious onset of pain 2 months after re-starting running.




This lady has had a massive change in her exercise profile and will have therefore lost a lot of strength and conditioning.

She has had a huge change in her social interactions due to loss of work and classes. Can this be improved?

She is frustrated and low in mood which means she is pushing herself hard on her run and may also be altering her pain processing. One run a week is insufficient to build decent running condition.

The car ergonomics need to be looked at as this is an identifiable aggravating factor, and something she is doing several times a day.




Post-natal depression. Now ‘ok’, but still finding it ‘tough’.

Sleep still very disturbed, (x1-2 a night every night). Not always the baby but she feels she has ‘lost the habit of sleeping’.




Exercise may well be an important part of the Mx of this lady’s mental wellbeing and therefore we need to aim for more than x1 week.

Sleep deprivation alters down-regulation of pain and also ability to cope and mood. Exercise may help with normalisation of sleep pattern.




No indication for imaging. Non-traumatic, bilateral, no effusions.

Education around the fact it is a pressure pain caused by loss of conditioning to cope with running load. No need to be worried.

Recommend looking for a buggy-fit class to help exercise with baby and social isolation.

Look at car ergonomics. Can steering wheel come out more to enable seat to go back further so knees less flexed?

Discuss what she feels she could realistically manage at home with respect to exercises. Suggest three exercises, alternate days to light fatigue to address global strength and motor control.

Can she discuss with her husband that instead of 1 run at the weekend where she pushes herself, she does x2 easier runs a week at this stage? (Perhaps combining fast walk with 1-mile jog in the middle)

No downhill running at the moment.

Ultimately help her recondition and safely build up her running volume.


60-year-old retired female with 6 week history of severe knee pain.


Right sided lateral knee pain. 8 out of 10 at worst.

Knee feels unstable and some ‘giving-way’ associated with sharp pain. Slightly swollen all round. No locking. Tearful. Has just retired and was really looking forwards to active retirement. Fearful she will not have the retirement she had anticipated.

Night pain


Thoughts: Giving way may be due to pain inhibition as pain of 8/10 likely to disrupt dynamic control.

The night pain requires further questioning. Are there any further red flags or could it signify bone oedema which frequently presents as night pain?


Aggravating Factors.


Stair descent virtually impossible

Walking downhill

Getting out of a low chair.

Kneeling impossible due to pain.

Crouching possible due to pain.



This sounds very much like the PFJ. Pain on stair descent in my experience tends to be more associated with joint surface problems.




No problems until 6 weeks ago. Retirement present to herself was a trek up Kilimanjaro with her husband. The pain on the descent was so severe she had to do some of the descent backwards. On return to the UK she had a rheumatology opinion. The consultant requested an MRI which showed, (Grade IV degenerate change and associated bone marrow oedema in the lateral facet of the PFJ.). Told nothing much that she could do and that she needed to review her retirement aspirations and accept she was heading towards a knee replacement. The patient is really upset and worried about the label of osteoarthritis she has been given.




Grade IV degenerate change does not develop in 6 weeks, and in fact the degeneration on MRI probably would have looked identical two months ago. The new feature is likely to be the bone marrow oedema which is associated with pain, especially in the lateral PFJ, and would fit with the night pain. Until 6 weeks ago she was managing perfectly well.

The label of ‘degeneration, and, ’osteoarthritis’ are terribly catastrophic for this lady. The worry and anxiety about the future is as much as a problem to her as the pain itself. It is too premature to suggest gross changes in long term lifestyle and suggest this will end in TKR.

Can we turn this around through education for us to view that we have the ‘heads up’ about the joint and that with smart use and staying strong she can be as she was 8 weeks ago once the oedema has gone?




Small effusion. Stiff patella. Lateral tilt.



The effusion will further inhibit the quads and increase the feeling of instability.

The stiff patella especially tilted laterally will further increase load through the lateral PFJ. This is the very area we need to offload to allow the bone marrow oedema to dissipate.




Poor firing of VMO and wasting through the vmo compared to the contralateral side.




This may not have been an initial driver and may be as a result of the pain and swelling, but nevertheless leaves the joint unprotected and vulnerable in the long term.


Weight bearing assessment.


Right leg tibia externally rotated compared to left.

No single stance assessment possible as too sore but double stance mini-squat had bilateral femoral adduction and internal rotation. Gets out of a chair with this movement pattern too.



What is externally rotating the tibia as this will increase lateral PFJ contact pressures? Movement patterning with adduction and IR increases lateral PFJ pressure.


Muscle length.


Two things of note are very tight right hip flexors on modified Thomas test, and tightness through ITB complex, (ie ITB and its proximal contractile origins).




The hip flexor tightness will lead to a loss of hip extension and hence greater knee flexion in terminal stance. This will increase PFJ pressure.

The ITB complex tightness will be causing the tibial external rotation via its tibial attachment.




  1. Alleviate fear and explain that the bone oedema is reversible, and it is that not the worn cartilage that is the source of the pain. Ask her to view it as too much ‘pressure’ under the knee cap, and we can alter that. She needs to consider using walking poles in the future for hill walking especially the descents, and where possible avoid routes with very long, prolonged descents.
  2. Movement re-education. Get her to become super aware of foot-knee-hip in a line for stairs, getting out of chairs and hill descent in particular.
  3. Stretches for TFL and hip flexor.
  4. Q brace to be worn asap for 6-8 weeks to off load lateral facet.
  5. Pain free light quads to be built up avoiding high PFJ stress long term.
  6. Little and often light self patella mobs to be taught to patient.