A surgeon’s case for conservative MSK care | Viewpoint

As a practicing orthopedic surgeon, my goal is always to strive for an evidence-based approach. Not only do I perform surgeries as a way to address musculoskeletal (MSK) issues, but increasingly, I also steer patients toward a nonsurgical approach.

Dr. Benedict Nwachukwu

MSK issues are a massive hindrance globally. In the U.S., MSK conditions are the leading cause of long-term disability and rank third in how common they are and how much they affect overall health. MSK conditions represent a growing health burden, responsible for an economic cost of $980 billion annually.

Lower back pain alone is the leading cause of disability worldwide. Oftentimes patients will seek me out, hoping that surgery is the fastest way to healing, but the truth is that for most, surgery is not the best solution.

Rethinking healthcare's silver bullet solution habit

In healthcare, I’ve observed that patients often look for quick fixes — surgery, injections, pain medications — to resolve complex, chronic issues like MSK conditions. But as we all know too well, in reality, there is no one-size-fits-all solution.

Conservative care, especially physical therapy, remains underutilized despite strong evidence supporting its effectiveness. A significant percentage of MSK surgeries could be delayed or avoided with appropriate conservative treatment.

Despite the overwhelming evidence on physical therapy’s efficacy, patients frequently show up in my office having bypassed this step altogether. Many come looking for answers, and instead of scheduling surgery, I find myself educating them on their diagnosis and recommending less-invasive options first. This gap in care reflects a broader systemic issue: Conservative options are often seen as a detour, not a first-line treatment.

Lessons from the NBA bubble

An example of conservative care’s power came during my time serving as a physician in the NBA bubble during the COVID-19 pandemic.

In that unique environment — closed off from the outside world and without easy access to surgical interventions — we worked to keep elite athletes healthy with conservative therapies alone, focusing on preventive care even more than we would during a typical season. We engaged in multistakeholder collaboration between the strength coaches, athletic trainers, and musculoskeletal providers.

Guess what? It worked. While there were limited surgeries, the vast majority of players recovered through conservative approaches alone with the care of our multidisciplinary teams.

While the real world doesn’t function like the NBA bubble, as a surgeon, it’s a reminder that collaborative, proactive, research-driven conservative care is effective and can deliver successful outcomes in a hybrid environment.

My wish list for the future of MSK care

Today’s patients are increasingly informed and empowered. They understand that a therapist who specializes in hip arthroscopy recovery isn’t necessarily the best choice for someone recovering from a hip replacement. This growing demand for specificity — combined with provider specialization — underscores the need for more personalized, nuanced treatment pathways.

I would love for more patients to engage nonoperative clinicians before meeting surgeons like me. In a perfect world, I would see patients after they have explored more conservative options because surgery after an initial trial of conservative care ensures that surgical care is both necessary and appropriate. As we strive to adhere to evidence-based medical approaches and further incorporate conservative measures, there is an opportunity to embrace hybrid MSK care.

By combining in-person and digital care models, we can address the complexity of MSK conditions more effectively. In-person care allows for hands-on therapy, which is essential for techniques like manual therapy or myofascial work. Meanwhile, digital platforms expand access, increase provider capacity, and offer continuity of care for patients in remote or underserved areas.

Hybrid approaches also support ongoing patient engagement. Patients frequently follow up with me with questions about exercises they’ve found online. A digital care plan tailored to their diagnosis provides them with the guidance and confidence they need — outside the clinic, at home, and on their own time.

We must also recognize that certain populations and conditions are historically underserved when it comes to conservative MSK care, including maternal health, targeted joint conditions, and surgical care, such as knee and hip replacements. These are areas where high-fidelity, specialized conservative support can drastically improve outcomes.

This approach not only benefits surgeons like me, but also hospitals and health systems. By treating conservative care as part of the care continuum, there is an opportunity to drive patient engagement, build trust, and ultimately retain loyal patients within the system.

The evidence is clear: Surgical outcomes are best when procedures are performed after a full course of conservative treatment and in the setting of a demonstrated functional decline. Too often surgery is performed prematurely or in high-functioning individuals; both scenarios can lead to less favorable outcomes.

Meeting patients where they are

The future of MSK care is not confined to a binary choice between surgery and therapy. It’s personalized, hybrid, and guided by evidence. Conservative management should be the starting point. And surgeons like me must play a role in promoting this shift.

By embracing technology, personalizing pathways, and empowering both patients and providers, we can close care gaps, reduce unnecessary surgeries, and — most importantly — help people feel better, move better, and live fuller lives.

Because sometimes, the best thing a surgeon can say is, “You don’t need me yet.”

Dr. Benedict Nwachukwu is an orthopedic surgeon and specialist in hip, knee, and shoulder surgery at the Hospital for Special Surgery (HSS).