Clinical synthesis based on the most recent meta-analyses and international consensus statements: Winters 2018, Hamstra-Wright 2015, Warden 2014, Marques 2025 and the LIMP 2025 debate.

Tibial periostitis, more rigorously called medial tibial stress syndrome (MTSS) in the scientific literature, is one of the most common overuse conditions in runners and military personnel.¹ The historical term “periostitis” is misleading: the data do not support a predominant periosteal inflammation. The pathophysiology remains debated, between bone overload of the tibia, related to bone stress injuries (BSI), traction at the musculo-aponeurotic insertions, or both.²,¹³

How is this condition defined, who does it affect and what are the risk factors?

MTSS is defined as exercise-induced pain along the posteromedial border of the tibia.¹ The consensus diagnostic criterion, prospectively validated by Winters and colleagues (BJSM 2018), requires that the pain be reproducible on palpation over at least 5 continuous cm.³ This “diffuse” character is essential to distinguish it from a stress fracture, whose pain is focal.

The epidemiology has been clarified by several recent systematic reviews 🏃:

• In the recreational and competitive runner, the incidence of MTSS ranges from 5-19% depending on the cohort (Lopes 2012, Hamstra-Wright 2015).⁴,⁵
• In military recruits, the incidence reaches 35-56% according to the narrative review by Alessa et al. 2024 (Cureus), with a historical study by Yates & White 2004 (AJSM, n = 124 naval recruits) reporting a 35% incidence over 10 weeks of training.⁶,⁷
• MTSS accounts for 13 to 17% of all running-related injuries (Lopes 2012).⁴
• The Saad 2025 scoping review confirms the wide geographical heterogeneity: prevalence of 5.4% (USA) to 69.5% (India) depending on the practice setting.⁸

The reference meta-analysis by Hamstra-Wright et al. (BJSM 2015) included 21 studies, of which nine factors were eligible for pooling, and highlighted only four significant risk factors, all expressed as weighted mean difference (MD):⁵

• Higher body mass index (BMI) (MD 0.79; 95% CI 0.38 to 1.20).
• Increased drop of the navicular (navicular drop, MD 1.19 mm; 95% CI 0.54 to 1.84): marker of excessive pronation.
• Increased ankle plantarflexion range of motion (MD 5.94°; 95% CI 3.65 to 8.24).
• Increased hip external rotation range of motion (MD 3.95°; 95% CI 1.78 to 6.13).

Ankle dorsiflexion and the Q angle are, on the contrary, clearly ruled out by this pooling.⁵ Female sex and a history of injury do not appear in it: only continuous variables, reported as means and standard deviations in at least three studies, could be entered. These two factors come from other studies. In the naval recruits of Yates & White 2004, 53% of women developed MTSS versus 28% of men, a relative risk of 2.03.⁷ The meta-analysis by Newman 2013 (Open Access J Sports Med), conducted in runners, for its part finds female sex (RR 1.71; 95% CI 1.15 to 2.54) and a history of MTSS (RR 3.74; 95% CI 1.17 to 11.91) among the significantly associated factors.⁹

What happens in the body and how does the condition evolve naturally?

The modern pathophysiology of MTSS, supported by the critical reviews of Moen 2009, Beck 1998 and Warden 2014, mainly describes a bone overload of the tibial cortex rather than a simple periosteal inflammation; the role of traction remains debated.¹⁰,¹¹,²,¹³ The central mechanism is a repeated mechanical overload that exceeds the bone’s capacity to adapt by remodelling. 🦴

The process unfolds in several stages:

1. Cumulative load: repeated running impacts induce accelerated bone remodelling.
2. Resorption / formation imbalance: if volume or intensity exceeds adaptation, the rate of osteoclastic resorption exceeds osteoblastic formation.
3. Microdamage and cortical porosity: the negative balance leads to an accumulation of microfractures, increased porosity of the tibial cortex and decreased bone stiffness.²,¹¹
4. Diffuse pain: this stress reaction manifests clinically as the characteristic pain over ≥ 5 cm.

A histological analysis (Johnell 1982, cited by Beck 1998) showed that the lesion involves not only the periosteum but also the bone cortex and the marrow, definitively redirecting management towards mechanical load management rather than towards anti-inflammatory drugs.¹¹

The natural course can be unfavourable if the load is not modified. Warden et al. (2014) describe a clinico-radiological spectrum ranging from normal adaptive remodelling to complete fracture, passing through stress reaction (bone oedema on MRI, Fredericson grade 1-3) and incomplete stress fracture (Fredericson grade 4).²,¹² Continuing training despite pain promotes the coalescence of microdamage.

How do you assess and diagnose tibial periostitis (MTSS) with certainty?

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The diagnosis of MTSS rests essentially on clinical examination, with sensitivity and reliability prospectively validated by Winters 2018 in 46 patients (high inter-examiner kappa for palpation of the painful length).¹ Imaging is not necessary as a first-line step, except in case of diagnostic doubt or suspected stress fracture. 🏃

Which questions should you ask to understand the patient and their history?

The history-taking aims to reconstruct the history of the injury and to identify training errors, the main triggering factor.² The areas of questioning:

• Pain characteristics: dull, diffuse pain along the distal third of the posteromedial border of the tibia, appearing during exercise, possibly easing at first after the warm-up, then returning with greater intensity when the activity is continued or stopped.²,³
• Training history: any rapid increase in volume, in intensity, in frequency or change of surface (track to road) or of footwear within the 4 to 6 weeks preceding the symptoms is suspect.⁴
• History: the history of MTSS or running injury is one of the strongest predictors of recurrence.⁵
• Systemic factors: systematically ask about energy intake, the menstrual cycle in women, a history of stress fractures, glucocorticoid use (flags for RED-S and high-risk BSI).
• Biomechanical factors and equipment: type of footwear, wear, insoles, foot type (more pronated = increased risk, with RR 1.7 in Yates 2004).⁶

Which clinical tests should you perform and which other conditions should you rule out?

The central clinical test is the “Shin Palpation Test”: palpation reproduces the pain over a continuous length of at least 5 cm along the posteromedial border of the tibia, generally in its distal third. Inter-examiner reliability was shown to be good to excellent (Winters 2018, kappa 0.76).¹ 🔬

Other tests are useful:

• Hop test (single-leg hop on the spot, 10x): sharp, focal pain should raise suspicion of a stress fracture rather than MTSS.⁷
• Fulcrum test: bimanual pressure on the tibia; positive if localised pain suggestive of a fracture (Milgrom 2021).⁷
• Functional tests: single-leg heel raises (ability to do 20-30 repetitions without pain = progression criterion), single-leg squat (looking for pelvic drop and dynamic valgus).

The critical differential diagnosis is the stress fracture of the tibia, placed by Warden 2014 on the same continuum.⁸ The signs pointing towards a fracture:

• Very localised pain (< 5 cm) at a point of exquisite tenderness.
• Pain at rest, even nocturnal (red flag).
• Positive hop test.
• Persistence despite correctly applied rest.

The chronic exertional compartment syndrome (CECS) presents with predictable cramping pain, increasing during exercise and disappearing within a few minutes of stopping. The reference diagnostic test remains measurement of intracompartmental pressure, as confirmed by the recent systematic review Dean 2024 (J ISAKOS, 25 surgical studies, 1018 patients; return to sport after fasciotomy ranges from 26 to 100%).⁹,¹⁰

The entrapment of the popliteal artery, which is rarer, can mimic MTSS: look for loss of the dorsalis pedis pulse on resisted plantarflexion and confirm with dynamic Doppler ultrasound.

Should patients with MTSS be classified, and for what benefit?

Yes, classifying MTSS helps to assess severity, set a prognosis and guide the rehabilitation strategy, in particular the return to running.

A 4-grade clinical classification, derived from Galbraith & Lavallee (2009) and widely used:¹¹

This grading has a clear prognostic value: grade 1 allows continuation of a modified activity, whereas grade 4 requires rest from sport and a thorough reassessment (suspected associated stress fracture).

For suspected BSI cases, the Fredericson MRI classification (1995) remains the reference:¹²

• Grade 1: isolated periosteal oedema.
• Grade 2: marrow oedema visible on T2 sequences.
• Grade 3: marrow oedema on T1 and T2 sequences.
• Grade 4a: multiple areas of intracortical signal.
• Grade 4b: visible fracture line (significantly longer recovery time).

The validation of this MRI classification by Nattiv 2013, confirmed by paediatric studies (Stein 2020), shows that grade 4b significantly prolongs the time to return to sport.

Critique and controversy: the “MTSS → LIMP” debate (Anderson 2025)

🤔 The nomenclature itself has been debated for a long time. The term “periostitis” is anachronistic because the histological data do not support a predominant periosteal inflammation.¹¹ More recently, Anderson et al. (JOSPT 2025) propose renaming MTSS as LIMP (Load Induced Medial-Leg Pain).¹³ Their argument:

• The term “tibial stress” is easily confused with “bone stress injury” (BSI), leading to unjustified excessive rest.
• The exact pathophysiology of MTSS remains debated: bone overload, traction of the deep crural fascia by the soleus/tibialis posterior, or both?
• “LIMP” directs management towards load management without presupposing the underlying pathology.

This proposal is not yet consensual but it reflects an important conceptual shift: clinically distinguishing MTSS (diffuse pain, low risk of rapid progression) from BSI (focal pain, potentially high risk) is more relevant than a purely etymological debate.

The effectiveness of MTSS treatment rests on rigorous management of mechanical stresses and the progressive increase of tissue capacity to tolerate them.¹ Exercise and education far outweigh passive therapies in terms of level of evidence.

Where do you start? What is the recommended hierarchy of interventions?

The initial and most crucial intervention is management of the load (load management).¹,² This does not mean complete rest, which deconditions the tissues, but a reduction of activity to a level that does not provoke pain during, after or the day after exercise. The therapeutic hierarchy:

What is the place of exercise, and is there a superior approach?

Therapeutic exercise is a central pillar. 🏃 It aims to improve the capacity of the lower-leg complex to absorb and transmit forces. The programmes share the principle of progressive loading (Warden 2014).¹

In runners, the most recent systematic review (Teles 2026: three trials, 130 runners) finds no clearly superior non-invasive treatment: arch-support orthoses combined with multimodal management reduce pain in the short term against sham, with no lasting effect, and added exercises do no better than their comparators.¹¹ Load management and education therefore remain the first line by pathophysiological reasoning, with no trial to separate them.

Priority muscle targets:

• Soleus and tibialis posterior: major pivots of pronation control and shock absorption in running (Verrelst 2014).³
• Hip abductors and external rotators: a recent RCT by Lashien et al. (J Orthop Surg Res 2024, n = 40 MTSS runners) shows that 8 weeks of functional strengthening of the hip abductors, combined with a standard physiotherapy programme, significantly reduce pelvic drop and dynamic knee valgus, measured on 2D video during a single-leg step-down (not during running).⁴ This effect is consistent with the chain pathomechanics identified by Bramah 2018 (AJSM).⁵
• Foot intrinsics: useful for medial longitudinal stability.

The progression follows a classic model: isometric → concentric → eccentric → plyometric, always within a tolerable pain threshold (≤ 2/10 according to Crowell-Davis 2011).⁶

For prevention, the reference meta-analysis is now that of Marques et al. (Gait Posture 2025, 12 RCTs, 8197 participants, GRADE assessment):⁷

• The neuromuscular training (4 studies, 3887 participants) is recommended for prevention, with high certainty according to the authors.
• The anti-pronation orthoses (overpronation insoles) (4 studies, 1047 participants) are recommended for prevention, with moderate certainty, with a confidence interval that touches the point of no effect.
• The cushioning insoles (2 studies, 1571 participants) showed no preventive effect (high certainty): the authors advise against them for this indication. Neither static stretching nor specific socks are supported by the evidence.⁷
• This conclusion converges with the historical RCT by Bonanno 2018 (BJSM, n = 306 Australian naval recruits), which showed a 34% reduction in the combined risk of MTSS / patellofemoral pain / Achilles tendinopathy / plantar fasciitis with prefabricated orthoses.⁸

Manual therapies, shockwave therapy: how effective are they really?

Passive therapies are frequently used, but the evidence is heterogeneous:

The focused extracorporeal shockwave therapy (ESWT) has been the subject of encouraging studies (systematic review Bagherzadeh-Cham 2022, as well as the pilot RCT Moen 2012) showing a reduction in pain and time to return to sport in chronic MTSS.⁹ However, methodological heterogeneity remains high and shockwave therapy must never replace active treatment.

The passive manual therapies (massage, dry needling, mobilisations) have not demonstrated robust efficacy on the underlying pathology. They may provide short-term symptomatic relief but do not modify the bone overload.

Beyond the physical: education and psychological factors

Therapeutic education is probably the most cost-effective intervention. 🧠 It covers:

• The nature of the injury: MTSS is a load-induced pain, not a simple inflammation; this message rules out both anti-inflammatory drugs and complete rest. Pain that becomes focal, nocturnal or that does not settle should prompt a search for a stress fracture.
• Modifiable training errors: volume, intensity, surface, cadence, footwear.
• Interpreting pain: pain ≤ 2/10 + resolution within 24 h = tolerable overload; residual pain = overload to be corrected.
• Optimising systemic factors: sleep, nutrition (calcium, vitamin D), stress management, RED-S screening (see chapter 6).¹⁰

Preventing recurrence is a central issue: without appropriate management, the recurrence rate is high. It rests on two pillars: empowering the patient and planning a return to running based on criteria, not on a fixed calendar.¹

How do you make the patient an active participant in their recovery through self-management?

Therapeutic education is the cornerstone of prevention. 🏃‍♂️ Making the patient competent changes their role from passive to active, which is a major prognostic factor.²

Self-management is built around three levers:

1. Understanding the mechanism: the patient must understand that MTSS is the result of a load exceeding the bone’s capacity to adapt, not an inevitability.³
2. Daily monitoring tool: the training log (paper or app such as Strava/TrainingPeaks) recording distance, duration, perceived exertion (RPE), pain 0-10 makes it possible to objectify the cause-and-effect relationship.⁴
3. A simple “traffic light” rule: described by Moen 2009 and widely adopted:¹

Adherence to the home exercise programme is just as central. Progressive strengthening of the soleus, tibialis posterior and hip abductors must become a long-term maintenance routine, even in the absence of pain.⁵

When and how do you plan a safe return to running?

Return to running is a process that is progressive, individualised and criteria-based. 📈 Rushing the return is one of the main causes of recurrence.

Functional prerequisites before resuming running:

• Brisk walking for 45 minutes without any pain.¹
• Ability to perform 20 to 30 single-leg heel raises without pain.
• Negative hop test bilaterally.
• No pain on palpation at rest.

The graded protocol of Moen 2009 remains the reference: a progressive walk/run alternation over several weeks, respecting the tolerable pain threshold. One guideline (not validated by RCT but widely adopted) is not to increase the total running volume by more than 10% per week.⁶

During this phase, three parameters must be monitored:

1. Pain: ≤ 2/10 during and after, resolving within 24 h.
2. Running technique: this is the ideal time for stride re-education (gait retraining). An increase in cadence of 5-10% significantly reduces tibial impact forces (Crowell-Davis 2011, Luedke 2016).⁷,⁸
3. Strengthening: continue and intensify in parallel, introduce plyometrics when tolerated.

Critique and controversy: the “10% rule” and pronation

💡 The famous “10% rule” of weekly increase is a clinical heuristic, not a rule validated by a high-quality controlled trial. Some trained runners tolerate more; novices and post-injury patients may need an even slower progression. The individualisation guided by pain takes precedence.

The excessive pronation (increased navicular drop) is a robust risk factor (Hamstra-Wright 2015) but the routine prescription of orthoses is not universally beneficial. The Marques 2025 meta-analysis (GRADE) retains anti-pronation orthoses for prevention, with moderate certainty; as treatment, their place remains to be individualised according to the biomechanical profile.⁵

Clinical cases offer valuable insight into the practical application of evidence-based principles, provided they are placed correctly in the hierarchy of evidence (level 5 according to the Oxford CEBM). 🧐

Real case: novice runner, Ramteke 2024

The case report by Ramteke & Jaiswal (Cureus 2024, PMC 11417438) illustrates typical management of MTSS in a novice runner.¹ Presentation:

• Patient: 22-year-old man, novice runner who had been running irregularly for six months, four to five days a week, 30 to 45 minutes.
• Symptom: anteromedial pain in both tibiae, appearing gradually after about 1 km on concrete, returning after 700 m despite four days of rest; stopped running after two to three weeks.
• Examination: normal X-ray; pain 7/10 on exertion and 8/10 on walking, grade 3 tenderness on palpation, stiffness of the plantar flexors on both sides, dorsiflexors, invertors and evertors at 4-/5.

The multifaceted management over 6 weeks:

• Phase 1 (weeks 0 to 2): education (running pattern, footwear, surface), stopping running for at least three days, cryotherapy, TENS, muscle energy techniques, talocrural and subtalar mobilisations, taping every other day.
• Phase 2 (weeks 2 to 4): plantar flexor stretching, treadmill walking then alternating walking and running, balance on an unstable platform, strengthening of the dorsiflexors and invertors with an elastic band.
• Phase 3 (weeks 5 and 6): weighted heel raises, squats and lunges, gradual return up to 30 minutes of continuous running.

Result: pain from 8/10 to 0/10, LEFS score from 32 to 100, MTSS score from 9/10 to 0/10, and return to 30 minutes of continuous running.¹ This single case, of evidence level 5, shows a favourable course with simple principles (load management, progressive exercise, education); it does not allow generalisation.

Another recent RCT (Lashien 2024, n = 40 MTSS runners) clinically confirms the added value of functional strengthening of the hip abductors over 8 weeks, with significant improvement in pelvic drop and dynamic knee valgus compared with the physiotherapy programme alone.²

The diagnostic challenge: when MTSS mimics another condition

Three major mimics must be systematically ruled out:

• 🔍 Stress fracture of the tibia: the shift from diffuse to focal pain is a warning sign. Milgrom 2021 (n = 429 elite recruits) prospectively validated that the combination “pain + focal tenderness over < 1/3 of the tibial length + positive hop or fulcrum test” identifies fractures effectively.³ MRI (Fredericson grading) remains the reference imaging.⁴
• 🔍 Chronic exertional compartment syndrome (CECS): predictable cramping pain appearing after a few minutes of running and disappearing quickly on stopping. The systematic review Dean 2024 (J ISAKOS, 25 surgical studies, 1018 patients operated on) confirms that intracompartmental pressure measurement remains the diagnostic reference test; the rate of return to sport after fasciotomy varies from 26 to 100%.⁵,⁶
• 🔍 Popliteal artery entrapment: rare but to be considered in the presence of vascular symptoms (paraesthesia, dead-leg sensation); the key sign is loss of the dorsalis pedis pulse on resisted plantarflexion, confirmed by dynamic Doppler ultrasound.

Study of complex cases

Some cases of MTSS prove recalcitrant despite well-conducted rehabilitation. The recent literature (Tenforde, Warden) highlights three areas to explore in such cases:

1. Systemic factors (RED-S): energy intake that is insufficient relative to expenditure (Relative Energy Deficiency in Sport) compromises bone health and recovery.⁷ See the dedicated chapter below.
2. Psychological factors: kinesiophobia, catastrophising and performance anxiety can slow the return to sport; a cognitive-behavioural approach combined with therapeutic education is then indicated.
3. Imaging to stratify: faced with chronic or bilateral MTSS, MRI (high-resolution T1/T2 sequences) makes it possible to place the patient on the Fredericson continuum and to differentiate pure MTSS from low-grade BSI.⁴

Any recalcitrant, recurrent or bilateral MTSS should lead the clinician to assess the systemic background of the patient. The best-documented factor, and the most frequently underdiagnosed, is the RED-S (Relative Energy Deficiency in Sport), recognised by the IOC since 2014 and profoundly updated in 2023.¹,²

What is RED-S and when should you think of it?

RED-S describes a multisystem syndrome resulting from insufficient energy availability (low energy availability, LEA), that is, a caloric intake too low relative to sporting expenditure, independently of any formal eating disorder.² It replaces and broadens the older concept of the “female athlete triad” (Nattiv 2007) by recognising:

• The condition affects both sexes, despite a higher prevalence in female athletes.
• The consequences go well beyond bone health: cardiovascular, immune, endocrine, psychological, performance.
• The 2023 IOC consensus introduces the REDs CAT2 (REDs Clinical Assessment Tool, version 2), which classifies risk on four levels (green, yellow, orange, red) accompanied by training and competition recommendations; its use is a doctor’s responsibility; the physiotherapist refers.²

The link with MTSS is direct: chronic LEA impairs bone healing, lowers bone mineral density and increases the risk of all bone stress injuries (BSI), from moderate MTSS to high-risk stress fracture.³,⁴ A study by Kraus, Tenforde et al. (BJSM 2019) in 156 male middle-distance runners showed that athletes with a high “Triad cumulative risk” score have a higher rate of BSI: the phenomenon is not exclusively female.⁵,⁹

BSI risk stratification: from MTSS to high-risk fracture

MTSS is often grouped with bone stress injuries (BSI), of which it would be the mildest form (relationship debated). BSIs are divided into low-risk and high-risk sites for complications (slow healing, non-union, complete fracture).⁴,⁶ The 2025 update of the Female Athlete Triad Coalition places the femoral neck, the navicular, the anterior tibia and the fifth metatarsal among the high-risk sites.⁸

This stratification is crucial because it determines:

• Imaging: MRI (Fredericson grading, more sensitive than scintigraphy) is the examination of choice to confirm and stratify a suspected BSI.
• The mode of offloading: walking remains allowed for low-risk BSI; complete offloading is required for high-risk BSI (in particular anterior tibial cortex “dreaded black line”).⁴
• Referral: any suspected high-risk BSI should lead to a rapid specialist medical consultation.

An international Delphi consensus on BSI (Hoenig 2025, BJSM: 41 members, agreement on 41 statements out of 58) proposes a multifactorial approach to identify and manage them.⁷ The Hoenig 2022 review emphasises that low-grade BSIs can progress to severe grades if neglected, and that management combines activity modification, nutritional optimisation and consideration of risk factors, including RED-S.⁶

Critique and controversy: is RED-S over-diagnosed or under-diagnosed?

🤔 The diagnosis of RED-S remains debated. Main criticisms:

• The precise biological markers of chronic LEA (LH pulsatility, T3, IGF-1) are difficult to obtain routinely; the REDs CAT2 is still recent and needs large-scale external validation studies.²
• The causal attribution between LEA and an individual BSI remains probabilistic, not deterministic.
• But underdiagnosis probably predominates: most runners with recurrent BSIs are never assessed for their energy status.⁵

The recommended pragmatic approach: systematic clinical screening in any patient with recurrent or bilateral MTSS, or MTSS occurring in an at-risk athlete (gravity-restricted sport, dietary restriction, amenorrhoea). If in doubt, prompt referral to a sports physician or a multidisciplinary team (doctor, nutritionist, psychologist if relevant).

Translating the evidence into daily practice requires clinical skills, interprofessional communication and objective measurement of results. 🧑‍⚕️ This section provides a pragmatic framework.

When, and to which other healthcare professionals, should you refer?

Referral is a key skill of the modern physiotherapist. It rests on identifying situations that exceed their scope of practice or require multidisciplinary management.

To the sports physician or the GP:

• Presence of a red flag suggesting a stress fracture, a systemic condition or RED-S.
• Failure of well-conducted conservative treatment over 3 to 6 months, to consider imaging (Fredericson MRI) and a specialist opinion.
• Any suspected high-risk BSI (anterior tibia, femoral neck, sacrum).

To the sports physician or the sports nutritionist: any patient with RED-S flags (see previous chapter), recurrent MTSS, amenorrhoeic young athlete, weight loss, dietary restriction.

To the podiatrist: for fine biomechanical assessment, prescription of anti-pronation orthoses (recommended for prevention by Marques 2025, moderate certainty).¹

To the psychologist specialising in pain: in the presence of yellow flags (catastrophising, kinesiophobia, performance anxiety) that slow rehabilitation.²

The interprofessional collaboration improves results and the efficiency of the care pathway (Cochrane review Reeves 2017).³ Three keys: clear communication, shared objectives, mutual respect for skills.

How do you measure outcomes and overcome barriers to implementation?

The systematic use of PROMs (Patient-Reported Outcome Measures) is the modern standard for quantifying results. 📈 For MTSS:

• MTSS Score (Winters 2018, BJSM 52:1108-15): the only MTSS-specific PROM, 15 items measuring pain and limitation (standing, walking, sport).⁴ Reference tool to be used systematically.
• Lower Extremity Functional Scale (LEFS): generic lower limb tool, validated in French.
• NPRS (Numerical Pain Rating Scale 0-10): for daily pain (training log).
• UWRS (University of Wisconsin Running Scale) or VISA-A depending on context (multi-injury runners).

Assessing PROMs at the start, middle and end of treatment objectifies progress, facilitates shared medical decision-making and demonstrates the value of physiotherapy interventions.⁵

Implementing evidence-based practice meets documented barriers: lack of time, lack of critical appraisal skills, access to scientific resources.⁶ Practical solutions:

• Synthesised resources: clinical practice guidelines, Cochrane reviews, the PEDro database (free, methodological scoring), JOSPT Insights, BJSM/JOSPT podcasts.
• Journal clubs or monthly reading clubs, with demonstrated effectiveness for EBP culture.
• PROM scoring apps and digital logbooks for the patient (reduced administrative burden).
• Mentoring culture among clinicians.

Critique and controversy: from rigid protocol to shared decision-making

🤔 Three tensions persist in applying the evidence:

• “PROMs paradox”: their usefulness is demonstrated but their implementation remains low (administrative burden, difficulty of interpretation).⁷ The challenge is to turn a numerical score into a relevant clinical decision, without falling into a purely “accounting” approach.
• “Tyranny of red flags”: their individual predictive value is low and excessive focus can generate unnecessary imaging. It is better to use probabilistic clinical reasoning, integrating the body of clues into the patient’s overall profile.
• Standardisation vs personalisation: guidelines rest on population averages; the clinician treats unique individuals. The art of EBP is to integrate high-level evidence, clinical expertise and patient preferences.⁵