I used to do a lot of push-ups. Then, one day, my right shoulder abruptly said no más. Coincidentally, days later I saw my doctor. To be clear, I live by “See doctors, not too much, only when sick,” but my insurance policy insists on an annual visit. So once a year I skulk into the office and prove why doctors make awful patients—particularly when they’re washed-up, windbag, wiseacres who don’t practice medicine.
To his credit, however, my doctor is kind and attentive, and quickly noticed my wincing. After a brief shoulder exam he diagnosed a rotator cuff injury and began preparations for an MRI.
I demurred. “Oh, that’s alright doc, I’ll just do some PT. But thank you, really.”
Gently, and with concern, he offered “It’s important that you be imaged.”
“I’m imaged all the time!” I said, pulling out my phone and showing him selfies of me and my boys pretending to throw up.
Perhaps it was the cholesterol test (I declined), or the PSA (are you kidding??), or just my winning smile, but this was the final straw. He turned slowly from the phone to me.
“Uh-huh. Sure. You do PT.”
I concur!
The problem, of course, is not my doctor, a man who suffers me with unparalleled grace. It is orthopedics—and a decades-long unmasking.
When things work the way they’re supposed to in medicine, the sequence is simple: First, researchers prove a treatment works, then doctors adopt it widely. In many cases, orthopedics has skipped step one.
Since the advent of X-rays, orthopedists have used imaging as a crucial, and often primary, determinant of the need for surgery. This has led to miraculous cures for broken and deformed bones. But as imaging advanced well beyond bones, so too did the ambitions of orthopedic surgery. MRIs, CTs, and arthroscopes now detect endless ‘abnormalities’—a frayed meniscus, a bulging disc, a torn ligament, a ruptured tendon.
For orthopods, seeing such pictures is a primal call to action: Ug. Thing broken. Me operate.
They attack the imperfections by trimming, stitching, shaving, plating, pinning, and reinforcing. But in terms of scientific method, this approach skips step one—the part where trials show surgery helps. Instead, orthopedists have often published a few rosy case reports and voilà—Mikey liked it!—an entire surgical industry was formed.
Eventually, curious minds began performing the studies that should have come first. And one by one, some of orthopedics’ most common procedures began to fall.
Arthroscopic surgery for meniscus tears—performed hundreds of thousands of times each year—was tested against sham surgery, where patients were anesthetized and the surgeon simply pretended to operate. The real surgery was no better.
Arthroscopic ‘cleanup’ of arthritic knees collapsed the same way.
Vertebroplasty and kyphoplasty—cement injections meant to stabilize spinal compression fractures—followed the identical arc: widely adopted, then disproven by sham-controlled trials.
Even ACL reconstruction, long considered inevitable, now faces trials suggesting rehabilitation alone typically leads to comparable outcomes.
Now a study published last month in JAMA Internal Medicine is raising new questions about shoulders. In it, 602 Finnish adults aged forty-one and older underwent MRI scans of their rotator cuffs, the ring of muscles that powers the shoulder joint. About a third had shoulder pain, the rest had no shoulder problems at all.
Among those with shoulder complaints, MRI found potentially surgical abnormalities—tears, degeneration, tendinopathy—in 98 percent, a stunning number. But the number for shoulders with no problems dropped jaws even more: 96 percent.
Awkward.
These results align with sham surgery trials, which overwhelmingly suggest that exercise and physical therapy may often be a wiser, safer approach than the costly, invasive surgeries that millions of Americans still undergo each year.
Importantly, none of this means orthopedic surgery isn’t a profoundly important specialty. When bones are shattered, joints are deformed, or trauma disrupts anatomy, surgery can be miraculous. No randomized trial is needed to prove that repairing a fractured femur matters.
But those injuries represent only a fraction of modern orthopedic practice.
Much of the field now revolves around treating subtle structural abnormalities found on imaging under the assumption that fixing them will help.
But assumptions aren’t science—randomized trials are.
And once a treatment becomes routine, even if it rests on shaky evidence, it develops its own ecosystem. Training programs teach it. Hospitals invest in the equipment. Surgeons build careers around it. Patients come expecting it.
In theory, when a randomized trial shows a procedure doesn’t work, the practice should disappear. In reality, it often doesn’t.
Arthroscopic knee surgery continued for years after the sham trials. Meniscus operations still number in the hundreds of thousands annually. Rotator cuff repairs remain a thriving industry. Procedures that randomized evidence has debunked continue to generate billions in revenue and fill operating rooms across the country.
Medicine prides itself on being evidence-based. But surgical traditions, once established, can be remarkably resistant to evidence.
Why don’t these surgeries work? Probably because the intrinsic healing capacity of the human form has been perfected by a million years of evolution.1 Modern orthopedic surgery, at about a century, has some catching up to do.
In medicine, the order matters: test first, adopt later. Much of orthopedics did it the other way around, and we are still sorting out the consequences.
Which may be why I’m back to doing push-ups after some PT. Fewer push-ups, to be sure, than I used to do, but that’s because I’m getting on in years, and one thing that was clear from the Finnish study—the older the shoulder, the uglier the cuff.
