A recent case shared by the New York Times demonstrates the fragmented state of musculoskeletal (MSK) care. A 36-year-old athlete with severe, debilitating calf pain spent six years navigating a maze of clinicians. His treatments were largely dictated by the specialty of whoever he saw: physical therapists gave him exercises; orthopedic surgeons recommended boots or surgery; and cash-pay clinics sold him injections—all with minimal relief. Finally, a Stanford physiatrist broadened the diagnostic lens and discovered the true cause: a compressed popliteal artery. Following appropriate treatment, he was pain-free.
This diagnostic maze is not unique to rare conditions. Consider low back pain, managed by a long list of clinicians (e.g., orthopedic surgery, physiatry, primary care, physical therapy, chiropractic, psychology). An MRI showing age-appropriate changes often triggers a referral to a surgeon. If that surgeon suspects the hip, the patient is sent to a joint specialist, then perhaps a pain clinic. All the while, the patient is seeing a physical therapist and chiropractor on the side. Trial and error becomes the norm, and who you see dictates what you get.
This high number of involved clinicians could be beneficial if these specialists functioned as a unified group. The unfortunate reality of modern MSK care is that clinicians treating interconnected pathology are too often siloed from one another. Current infrastructure artificially divides anatomy (e.g., separating spine and joint care) and incentivizes specialization over collaboration, while conflicting guidelines, misinformation, and a sprawling wellness market compound the chaos. Driven by a system that rewards isolated interventions over comprehensive care, many receiving specialists default to their narrow lanes: a surgeon might look for a structural defect to repair, and a pain specialist might look for a generator to inject.
Contrast this disjointed journey with the aspirational infrastructure of modern cardiovascular care. Ideally, patients with complex heart disease are managed by an interdisciplinary Heart Team—a collaborative model spanning surgical, interventional, and medical specialties. MSK leaders are beginning to recognize the necessity of such a model, “running from prevention and performance through rehabilitation, regenerative medicine and, eventually, surgery if necessary.” To achieve this, here are three lessons MSK care can learn from cardiology.
Lesson One: Follow the Evidence
For decades, cardiologists reflexively stented narrowed arteries because it made intuitive mechanical sense. Yet, landmark trials like COURAGE, ORBITA, and ISCHEMIA proved this logic flawed: for stable angina, stenting did not prevent heart attacks or extend life better than optimal medical therapy. Cardiology has incorporated this reality into its guidelines, but like all procedure-heavy specialties, it struggles to abandon incentivized interventions when evidence shifts, as also seen with left atrial appendage closure.
MSK care is still emerging from its pre-COURAGE era. Though age-appropriate MSK changes (e.g., rotator cuff tears, herniated discs) are extremely common in asymptomatic adults, they still frequently trigger surgery. While fixing a structural defect is effective for a shattered femur, it often fails when treating multifactorial MSK pain. Sham-controlled trials repeatedly show that surgeries like meniscectomy, subacromial decompression, and lumbar fusion for chronic low back pain perform no better than non-operative care. Further, patients are inadequately counseled on the downsides of intervention, such as adjacent-level disease or accelerated osteoarthritis. The non-operative wing of MSK care is also at fault, heavily relying on contested treatments like epidural steroid injections. To be fair, MSK care is a uniquely difficult space. Unlike fields guided by objective metrics, MSK clinicians must navigate subjective pain and multifactorial decline. Generating high-quality evidence for these conditions is difficult but necessary.
Ultimately, MSK care must evolve from studying isolated treatments to designing cohesive, evidence-based pathways. Cardiology already does this: it pairs effective interventions with clinical pathways like GDMT for heart failure,1 informing treatment sequencing and providing objective failure thresholds (e.g., 90 days of optimal medical therapy with ejection fraction <35% before allowing procedural escalation). To build this in MSK care, we need rigorous trials that answer the most practical, pressing questions of the MSK patient journey: how to properly sequence and synergize therapies, distinguish normal aging from treatable pathology, rigorously define failure of conservative therapy, and optimize interdisciplinary coordination.
Lesson Two: Strive Toward Prevention
Readers of Sensible Medicine are justifiably skeptical of prevention, knowing that early detection can drive overdiagnosis and harm. Yet, preventive MSK care avoids the pitfalls of, say, cancer screening. Because joint decay is universal, proactive management is less about medicalizing healthy patients and more about delaying functional decline through low-risk treatments like exercise.2 We universally accept the premise of preventive cardiology: target systemic risk factors years in advance and treat adverse cardiovascular events as medical failures rather than inevitabilities. Such a perspective is sorely lacking in MSK care.
Let’s revisit Pam, a 64-year-old runner previously described in Sensible Medicine. Advised by a surgeon to stop running to preserve her knee,3 she gained weight and developed hypertension, hyperlipidemia, and anxiety. By viewing her issue through a mechanical lens and failing to appreciate the complex interplay of biological and psychological contributors, the surgeon triggered a metabolic cascade that accelerated her path to joint replacement.
Imagine if Pam’s case had been approached with the same proactive lens we apply to cardiovascular disease. In high school, a targeted training protocol could prevent an ACL tear and the accelerated arthritis that followed. In early adulthood, her MSK baseline could be quantified using DEXA, metabolic health screening, and MSK biomarkers to generate a personal risk profile. In midlife, tracking physical activity as a vital sign via remote patient monitoring or movement screening could catch deficits early, allowing for minimally invasive interventions such as exercise prescriptions,4 psychological and metabolic treatments, or orthobiologics like platelet-rich plasma.5 Later in life, rotational, balance, and power training, a high-protein diet, and creatine supplementation could be used to prevent sarcopenia and hip fracture.
To be clear, such an approach needs better evidence, and some of the mentioned modalities may not be proven effective. Nonetheless, offering an active, aging population little more than a surgical waiting game has created a massive vacuum eagerly filled by the booming wellness industry.6 MSK clinicians must reclaim this territory by developing legitimate, evidence-based prevention. Instead of chasing immortality or lifestyle panaceas, we can focus on preserving function for a higher quality of life as we age.
Lesson Three: Build Systems
Cardiology has historically dominated health system design because cardiac events carry high mortality. We want to prevent the leading cause of death and have invested heavily in the infrastructure to do so (e.g., 80% of Americans live within an hour of a cath lab, door-to-balloon times are consistently under 90 minutes, and AEDs are increasingly prevalent). MSK health differs in that its effects on patients and systems are not as readily apparent, often manifesting as years of functional decline and exacerbated comorbidities. We fear sudden death more than decades of disability, and our system design reflects that.
However, MSK care possesses a key advantage: patient motivation. Silent cardiac risk factors like high blood pressure rarely drive people to the clinic, but painful joints and backs do. Further, a low risk of acute mortality means that after ruling out red flags (e.g., cauda equina) with straightforward screening questions, digital care can serve as an effective front door.7 Given this reality—and the fact that MSK health is a top 3 healthcare expense—our failure to build better MSK systems is surprising. Despite some examples of successful innovation (e.g., integrated practice units), we often default to systems built for other purposes, funneling non-traumatic back pain into ERs designed to rule out mortality, and sending patients like Pam into surgeons’ offices for mild joint swelling.
To fix this, clinicians across disciplines and practice settings must rise above their silos to build cohesive care pathways that prioritize lifelong function over isolated interventions. We must improve triage to connect patients with the right clinician at the right time and establish coordination across broad, interdisciplinary MSK teams that take comprehensive, longitudinal ownership.
Matthew Allen is an incoming Physical Medicine & Rehabilitation resident at the University of Washington.
Jeffrey Krauss is a clinical assistant professor of Physical Medicine & Rehabilitation at Stanford, staff physician at the VA Palo Alto Health Care System, and Chief Medical Officer of Hinge Health.
Howard Luks is an orthopedic surgeon and author of the Substack Built to Move, Born to Heal: Notes on Midlife Fitness.
GDMT is a useful but not perfect example.
Unless, of course, that exercise is pickleball.
Running does not cause knee osteoarthritis.
Contrary to the claim that ‘we do not need to learn anything else about exercise,’ specific strategies matter.
Emerging treatments include peptides (e.g., GLP-1s), 15-PGDH inhibitors, and myostatin inhibitors.
Consider the books reviewed by Dr. Prasad or Dr. Cifu’s observations on medicine’s shifting role.
PHTI found positive outcomes for digital MSK solutions but mixed results for hypertension.
