CORR Insights®: Association of Unmet Social Needs With Level of Capability in People With Persistent Knee Pain

Where Are We Now?

The concept of movement has deep socioeconomic implications. At a high level, social standing and access determine how easily certain populations move throughout society. But on a more literal level, movement is also determined by socioeconomic factors. With regard to treating pain from knee arthritis, whether one can have surgery at all and how well a patient recovers afterward are tied to that patient’s financial situation. There are direct costs (insurance, copayments beyond insurance, and cash payments if a patient has no insurance at all), as well as indirect ones, such as lost wages and the support a patient might need to receive from family members or friends. And the societal burdens of knee arthritis run even deeper. Even to offer appropriate nonsurgical treatment of knee arthritis, there are considerable societal prerequisites. Consider the need for access to a physical space that offers or allows low-impact cardiovascular exercise. Consider the need for access to gym equipment, or to pools for aquatic therapy. Consider the need for access to healthy food options. These things are taken for granted by some but are not readily accessible to many. In recent years, orthopaedic surgery has made strides in our identification of existing disparities in the use of musculoskeletal care. But we still lack a full realization of their true societal impact. We must acknowledge that musculoskeletal health disparities are a form of disenfranchisement.

In their investigation, published in this month’s Clinical Orthopaedics and Related Research®, the authors of “Association of Unmet Social Needs With Level of Capability in People With Persistent Knee Pain” [1] observed that social health factors such as food insecurity and housing instability were associated with decreased capability in patients with atraumatic knee pain. Their perspective is refreshing and much needed. By evaluating the role of unmet social needs as it relates to a person’s ability to function in society in the setting of arthritis-related pain, the authors have appropriately reframed the conversation about the societal impact of musculoskeletal health. Based on the discoveries of this study, surgeons should attempt to assess the social needs of patients being treated for knee pain. It is clear from this investigation that surgeons need to give the same attention to surveys of socioeconomic status that we do to patient-reported functional outcomes.

Where Do We Need to Go?

Collectively, orthopaedic surgeons need to move toward positively affecting social policy for the benefit of our patients. The study by Lin et al. [1] reveals what is in essence a vicious cycle. Societal boundaries limit the effective treatment of chronic knee pain, which in turn limits a patient’s ability to overcome societal boundaries. Identifying this relationship is a correct initial step. We do not yet know how to assess the effectiveness of positive social initiatives on musculoskeletal quality of life. Before we can make effective recommendations about social policy, orthopaedic surgeons must broaden our investigative lens to further elucidate the relationship between arthritis-related pain and barriers to societal participation. Recently, we have effectively expanded our knowledge of the negative societal impact of musculoskeletal pain. We have developed a more nuanced understanding of how social factors increase the impact of musculoskeletal maladies such as knee arthritis. We now must find ways to empower disenfranchised populations to break the cycle. We need to be involved in developing policies that will ultimately decrease the social burden of arthritic pain.

How Do We Get There?

In the same way that populational health experts have developed metrics for the general health of a community, I believe we must work to develop similar metrics for the orthopaedic health of a population. Because social barriers vary among different communities, it will be important to develop survey studies to better understand the experience of people living in at-risk communities. Said survey studies would serve to target the specific elements of social health to be evaluated against patient-reported measures of musculoskeletal health. To do this effectively at a high level will require collaboration with specialists outside our field. Integrating the expertise of sociologists and social psychologists will be key in developing effective metrics of social orthopaedic health. Once we have developed such metrics, we can apply them to clinical risk stratification so we can intervene early in the treatment pathway. A more ambitious long-term goal is to develop prospective population studies to evaluate the effectiveness of social policy interventions on improving a community’s musculoskeletal health. Here again, success will depend on our ability to step out of our typical academic silos and engage experts in population health and policy. It is increasingly clear that musculoskeletal health factors largely into population health. Therefore, it is imperative that we play an active role in exploring how orthopaedic health affects social health and vice versa.