CORR Insights®: High Prevalence of Work-related Musculoskeletal Disorders and Limited Evidence-based Ergonomics in Orthopaedic Surgery: A Systematic Review

Where Are We Now?

Laborers often seek the care of an orthopaedic surgeon when they are approaching the limits of what they can expect from their body. People with new symptoms from gradual-onset degenerative conditions often misperceive the new symptoms as representing new pathophysiology [14, 24]. And if the new symptom is pain, they often misperceive the problem as an injury [11, 14, 16]. People who have, for their entire working lives, depended on their bodies for their livelihood may place inordinate and misplaced hope on our ability to pause, delay, or reverse the body’s aging process, and surgeons may try to fulfil this expectation. For years, rotator cuff tendinopathy was ascribed to activity in the form of impingement. Evidence has established that rotator cuff tendinopathy is an inherent, senescent process [4, 17]. Subacromial decompression is no better than simulated (sham) subacromial decompression [21]. Consider all those people we thought we helped. All we provided those people, using the strategic trauma that surgery ultimately represents, was false hope, a scar, and an unhelpful excision of part of their anatomy.

For many temporary processes such as enthesopathies (lateral epicondylitis or plantar fasciitis) and some tunnel tendinopathies [18], people often falsely associate painful activity with causing pathophysiology or preventing healing [8, 9, 22]. But no matter how active one is during painful activities, these problems resolve over time [12]. Others seek care for pain they experience with activity or limit activity because they falsely associate hurt with harm and have no detectable pathophysiology [26]. These are probably the aches and pains of normal physiology. I was thinking about that as I was playing bass guitar in my new band last weekend. If I thought the pain I felt in my fingertips and muscles indicated damage, I would not have played a note.

The study of Vasireddi et al. [25] addresses the laborer aspects of orthopaedic surgery. The authors systematically reviewed studies that addressed the prevalence of musculoskeletal disorders among orthopaedic surgeons because they are concerned that our daily labors may place us at risk. They also collected data about time off work, perceived current and future incapability to perform surgery, and speculations the studies made about potential exposures. There were notably wide ranges in prevalence between studies. The speculations addressed exposures to fatigue, vibration, torque, strain, and postural issues, all of which are highly debatable. I’m not sure whether this information helps us be healthier or enjoy our work more. And my concern is that the best evidence we have about the normal functioning of the human mind suggests that framing our aches and pains as work-related damage is going to make us more worried and less healthy. Words and concepts can reinforce less healthful mindsets [1, 5]. Consider, for instance, nocebo effects, where negative preconceptions result in more discomfort and incapability independent of pathophysiology [5]. If we are going to frame our aches as problems, we had better be correct.

Where Do We Need To Go?

Musculoskeletal pathophysiology is largely idiopathic and often associated with aging. Each of us who is blessed with a life that extends into our 80s can prepare for rotator cuff tendinopathy [23], as well as osteoarthritis of the knee [13], neck [10], and trapeziometacarpal joint [2]. There are variations in the age at which these pathophysiologies start and how severe they get, but those differences don’t seem related to exposures (such as activities) and are likely mostly genetically mediated. The President’s hair turns gray after 8 years in office, not from stress, but because of aging and depending on when they were genetically programed to lose melanin in their hair follicles. Orthopaedic surgeons can expect their labors to be increasingly more painful and fatiguing, not from physical or mental stress, but from aging. Tom Brady was an effective quarterback at age 45, but there is no possibility that his agility, strength, and endurance would allow him to continue at that level into his 50s. This is senescence, not damage. To the contrary, his notable athletic performance at age 45 can be credited to his activities.

People experience more discomfort and incapability when their bodily sensations are associated with unhelpful thoughts and feelings of distress [19, 22]. If we interpret our discomfort as injury, we are going to feel worse and do less. Contrary to what many of us learned as orthopaedic residents, evidence tells us that discomfort and incapability have a surprisingly limited association with pathophysiology severity [7, 20]. People can be extraordinarily adaptive. In the context of exercise, we would interpret fatigue and soreness as signs of a healthy workout. It’s probably best if we consider ourselves surgical athletes. And over the years, as aging surgical athletes.

My group studied the lifetime prevalence of musculoskeletal disorders among musculoskeletal surgeons [3], and this study was included in the current systematic review [26]. The findings were that surgeons had a higher prevalence of at least one nontraumatic pain than patients did and were more likely to report pain at more than one anatomic site, which we interpreted as surgeons being more aware of musculoskeletal disorders than lay people, taking note of them as they came, and remembering them more readily when asked. Second, my group found that patients were more likely to receive any treatment, including surgery, injection, nonopioid medication, opioid medication, or physical or occupational therapy, which we interpreted to mean that patients had less healthy thoughts and feelings about their musculoskeletal sensations, which evidence suggests is part of why they seek our care [6]. Third, patients missed work more often than surgeons, which we interpreted similarly. Surgeons notice their pains and accommodate them.

In my view, the evidence points away from strategies that promote concerns about, or limitations to, surgeons’ activities. The evidence points toward efforts to evolve one’s identity to match one’s body. I think that’s how surgeons continue to be effective into their 70s and 80s, not by protecting themselves by limiting or altering activity, and not even primarily through diagnosing and treating their ailments. I think the key surgeon health strategy is constant attention to a healthy mindset about their body’s sensations. This seems to me to be a key aspect of healthy aging.

How Do We Get There?

Given the evidence that unhealthy mindsets are more strongly associated with greater discomfort and incapability than levels of pathophysiology, we should, on principle, resist any theories that promote or reinforce unhealthy mindsets unless they are supported by sound, strong, consistent experimental evidence. If you’ve read this far and disagree with my interpretation of the evidence, the study you need to do is a randomized trial comparing a protection intervention with a mindset intervention to see which is associated with greater joy and effectiveness in orthopaedic surgery. Or you could try to prove that orthopaedic surgery causes or accelerates pathophysiology. But that’s unlikely and experiments would probably find it difficult to find an activity “signal” within the age-related and genetic “noise.”

Read This Next

• I suggest having a look at my group’s study comparing the lifetime prevalence of musculoskeletal pain among surgeons and patients [3].

• Read at least one study demonstrating that pathophysiology severity has a limited association with levels of discomfort and incapability among people seeking care, such as my group’s study using measures of rotator cuff pathophysiology severity [20].

• To get a sense of the relative influence of mental health and pathophysiology among people not seeking our care, read the population-based study of Kim [13], which found that an estimated diagnosis of major depression had as much impact on knee symptom intensity as the radiographic severity of knee osteoarthritis. I interpret the relatively greater association between symptoms and pathophysiology among people not seeking care, compared with little or no association in studies of people seeking care [7, 11], to reflect the levels of distress and unhelpful thinking that motivate people to seek specialty care.

• Finally, be sure to read about placebo [15] and nocebo effects [5] and the iatrogenic potential of the physician’s words [1].