Many Orthopedic Surgeries Don’t Work Better Than Placebo

Unlike drugs, orthopedic surgeries can be sold to the public before they undergo rigorous testing to ensure they are safe and effective. Thus, millions of surgeries for knee, shoulder, and back pain have been done without studies to confirm they actually work. Recently, research has found that many popular surgeries (but not all) work no better than a placebo. And yet these surgeries are still done at the rate of hundreds of thousands per year. This is something you should know if you are considering surgery, or in the business of treating chronic pain.

Knee Surgery

Osteoarthritis of the knee is common but does not necessarily result in pain — many people have arthritis and no pain at all. But surgery to correct arthritis is popular, numbering as many as a half-million per year in the U.S. alone. (1)

About 15 years ago, two of the most common procedures were debridement (removal of damaged cartilage or bone) or lavage (irrigation with saline solution). The goal of either surgery was removal of rough fragments of cartilage that may be irritating the joint. The surgery’s benefits were known to be not so impressive, so people started to wonder whether they were caused by placebo, or could be achieved with less invasive treatment.

To answer these questions, a study was done using a “sham” surgery: one group of patients received real knee surgery, and the other a fake, which involved just an incision on the skin. At several times over the course of a couple of years, the two groups reported their levels of knee pain and function. The result? The sham group did just as well as the surgical group at all points in time. (2) This strongly suggests the surgery worked by changing psychology, not structure.

This study was slow to have an effect on the behavior of surgeons. Years later, hundreds of thousands of these surgeries were still being performed at the cost of $3 billion a year. (3) Subsequent research confirmed they provide no more benefit than common sense interventions like exercise, weight loss, and the occasional use of over-the-counter pain medicine. (4) Debridement and lavage eventually became less common but were soon replaced by arthroscopic partial meniscectomy. But the new surgery proved to be equally weak. Like its predecessors, it worked no better than a sham.

In 2015, researchers summarized the results of nine studies on arthroscopic procedures for the knee and concluded that they showed little if any benefit, and the possibility for serious harm. (5) Further studies in 2017 came to similar conclusions. (5a)

A recent editorial in the British Journal of Medicine offered the scathing opinion that arthroscopic surgery for knee pain is: “a highly questionable practice without supporting evidence of even moderate quality.” (6) A clinical guideline issued in 2017 made a “strong recommendation against the use of arthroscopy in nearly all patients with degenerative knee disease” and noted that “further research is unlikely to alter this recommendation.” (7) In spite of this advice, arthroscopic knee surgery continues to be the most common orthopedic procedure in the U.S., with close to 700,000 performed each year. (6)

Why the disconnect between research and practice? The simple answer is that many doctors trust their personal experience over-controlled research. They will say they have seen surgery provide benefit after conservative therapies failed. Surely this sometimes occurs, but we should be skeptical that the cause is structural change in the knee. Instead, successful treatment for chronic knee pain, through surgery or otherwise, may be caused by complex changes in psychological or neurological processes.

Back Surgery

As with knees, there is a wealth of evidence that backs can have major structural damage and still not hurt. Further, backs can hurt a lot even when they have no apparent damage. In fact, this is quite common — most chronic low back pain is classified as “non-specific”, meaning it cannot be explained in reference to a mechanical or structural cause. Although there is only a poor correlation between back pain and structural back damage, there are many surgeries to correct any damage that happens to appear on an MRI. Several perform no better than conservative care.

For example, vertebroplasty attempts to treat back pain by injecting bone cement into fractured vertebrae. A study published in 2003 showed it works as well as no treatment at all after six weeks. (8) In 2009, two studies showed it worked no better than a sham procedure for fractures related to osteoporosis. (9)

Low back fusion is a common procedure and is intended to enhance low back stability. In 2013, the Spine Journal published a study comparing spinal fusion to non-operative treatments like cognitive behavioral therapy and exercise. It found no difference in long term outcomes and concluded that “the use of lumbar fusion in chronic low back pain patients should not be favored” over conservative care and exercise. (10)

In 2014, an analysis of multiple studies concluded that:

There is strong evidence that lumbar fusion is not more effective than conservative treatment in reducing perceived disability because of chronic low back pain among patients with degenerative spinal diseases. It is unlikely that further research on the subject would considerably affect this conclusion.(11)

As with knee surgery, the research showing the relative ineffectiveness of surgery has been slow to affect practice. Nikolai Bogduk, an internationally renowned anatomist and back pain expert, explains that:

Surgeons and others believe that surgery is effective for back pain. They base this belief either on their own experience or on observational studies. This belief is, by and large, not vindicated by the outcomes in well-reported clinical trials. Those trials indicate that only a small proportion of patients do well from surgery.(12)

Shoulder Surgery

The research on shoulder surgery is less clear, but recent studies reveal a similar pattern. MRIs consistently show that a great many people without pain have torn rotator cuffs. Despite this fact, the most common diagnoses to explain shoulder pain is “impingement” on the rotator cuff by the acromion process.

Surgeries to correct these conditions include rotator cuff repair, or acromioplasty, where a portion of the acromion is removed. In the United States, there are almost half a million of these surgeries performed each year, most of them on shoulders where the damage is degenerative as opposed to traumatic. (13)

Although we cannot rule out the possibility that surgery will be substantially more effective than exercise for certain patients (14), several studies have found that popular shoulder surgeries, such as acromioplasty, are no better than exercise. (15) Further, it has been shown that surgeries for labral repair and biceps tendinosis cannot outperform sham surgery. (16)

There is also evidence suggesting that when surgery is effective at relieving pain, it is not because of structural repair. (17) MRIs of repaired rotator cuffs taken within a year after surgery often show that the cuff has fallen apart again, even though the patient has recovered. According to Dr. Lawrence Gullotta, “When your rotator cuff is torn, you attribute all your pain and dysfunction to your torn rotator cuff, then you have it fixed and you feel better, but sometimes when you take an ultrasound or an MRI, the rotator cuff looks exactly like it did before you had the surgery.” (18)

A 2017 study compared two kinds of shoulder arthroscopic surgery (with and without decompression), and found that neither provided a clinically significant benefit over no treatment at all. (19) An editorial said these findings “send a strong message that the burden of proof now rests on those who wish to defend the standpoint that shoulder arthroscopy is more effective than non-surgical interventions.” (20)

A blog post in the British Journal of Sports Medicine summed up the situation as follows: “in the light of the current evidence base, the benefits of surgical intervention for the treatment of [shoulder pain] seem glorified and overrated.” (21)


Let me make something clear: None of the above means we should not trust orthopedic surgeons, or that surgery should never be used to treat chronic pain. Many surgeries have been proven to work and are definitely a good idea under certain circumstances. I personally know many people who have received excellent and ethical advice from their surgeons, and dramatic benefits from surgery. By contrast, I also know people who got a surgery that had been proven to be ineffective, were never advised of the relevant research, and ultimately did not get a good result.

I think the lesson here is that the medical establishment has some biases in the way it treats chronic pain. It favors treatments based on simple structural explanations for pain and tends to ignore complex neurophysiological processes that may be more important. We need to be aware of these biases and learn as much as possible about the complexity of pain so that treatment can be improved. And chronic pain clients need to ask their surgeons some good questions before going under the knife.


The above article is an adapted excerpt from my new book, Playing With Movement: How to Explore the Many Dimensions of Physical Health and Performance


1. Heidari, Behzad. 2011. “Knee Osteoarthritis Prevalence, Risk Factors, Pathogenesis and Features: Part I.” Caspian Journal of Internal Medicine 2 (2): 205–12.2.

2. Lubowitz, James H. 2002. “A Controlled Trial of Arthroscopic Surgery for Osteoarthritis of the Knee.” Arthroscopy 18 (8): 950–51.

3. Why ‘Useless’ Surgery Is Still Popular.

4. Kirkely, Birmingham, et al. 2008. “A Randomized Trial of Arthroscopic Surgery for Osteoarthritis of the Knee.” New England Journal. Vol. 359, 1097.

5. Thorlund, J. B., C. B. Juhl, E. M. Roos, and L. S. Lohmander. 2015. “Arthroscopic Surgery for Degenerative Knee: Systematic Review and Meta-Analysis of Benefits and Harms.” Bmj 350 (jun16 3): h2747–h2747. doi:10.1136/bmj.h2747.

5a. “Brignardello-Petersen et al. (2017). Knee Arthroscopy Versus Conservative Management in Patients with Degenerative Knee Disease: A Systematic Review. BMJ Open 7(5), e016114; Sihvonen et al. (2017). Arthroscopic Partial Meniscectomy Versus Placebo Surgery for a Degenerative Meniscus Tear: A 2-Year Follow-Up of the Randomised Controlled Trial. Annals of the Rheumatic Diseases. 77(2), 188–195.”

6. Järvinen, Teppo L N, and Gordon H Guyatt. 2016. “Arthroscopic Surgery for Knee Pain.” BMJ (Clinical Research Ed.) 354 (July). British Medical Journal Publishing Group: i3934. doi:10.1136/BMJ.I3934.

7. Siemieniuk, Reed A C, Ian A Harris, Thomas Agoritsas, Rudolf W Poolman, Romina Brignardello-Petersen, Stijn Van de Velde, Rachelle Buchbinder, et al. 2017. “Arthroscopic Surgery for Degenerative Knee Arthritis and Meniscal Tears: A Clinical Practice Guideline.” Bmj, j1982. doi:10.1136/bmj.j1982.

8. Diamond, Terrence H, Bernard Champion, and William A Clark. 2003. “Management of Acute Osteoporotic Vertebral Fractures: A Nonrandomized Trial Comparing Percutaneous Vertebroplasty with Conservative Therapy.” The American Journal of Medicine 114 (4): 257–65. doi:10.1016/S0002–9343(02)01524–3.

9. Kallmes, David F., Bryan A. Comstock, Patrick J. Heagerty, Judith A. Turner, David J. Wilson, Terry H. Diamond, Richard Edwards, et al. 2009. “A Randomized Trial of Vertebroplasty for Osteoporotic Spinal Fractures.” New England Journal of Medicine 361 (6): 569–79. doi:10.1056/NEJMoa0900563.

10. Mannion, Anne F., Jens Ivar Brox, and Jeremy C.T. Fairbank. 2013. “Comparison of Spinal Fusion and Nonoperative Treatment in Patients with Chronic Low Back Pain: Long-Term Follow-up of Three Randomized Controlled Trials.” The Spine Journal 13 (11): 1438–48. doi:10.1016/j.spinee.2013.06.101.

11. Saltychev, Mikhail, Merja Eskola, and Katri Laimi. 2014. “Lumbar Fusion Compared with Conservative Treatment in Patients with Chronic Low Back Pain.” International Journal of Rehabilitation Research 37 (1): 2–8. doi:10.1097/MRR.0b013e328363ba4b.

12. Bogduk, Nikolai, and Gunnar Andersson. 2009. “Is Spinal Surgery Effective for Back Pain?” F1000 Medicine Reports 1 (July): 27–29. doi:10.3410/M1–60.

13. Jain, Nitin B, Laurence D Higgins, Elena Losina, Jamie Collins, Philip E Blazar, and Jeffrey N Katz. 2014. “Epidemiology of Musculoskeletal Upper Extremity Ambulatory Surgery in the United States.” BMC Musculoskeletal Disorders 15 (1): 4. doi:10.1186/1471–2474–15–4.

14. Steuri, Ruedi, Martin Sattelmayer, Simone Elsig, Chloé Kolly, Amir Tal, Jan Taeymans, and Roger Hilfiker. 2017. “Effectiveness of Conservative Interventions Including Exercise, Manual Therapy and Medical Management in Adults with Shoulder Impingement: A Systematic Review and Meta-Analysis of RCTs.” British Journal of Sports Medicine, bjsports-2016–096515. doi:10.1136/bjsports-2016–096515.

15. Ketola, S., J. Lehtinen, T. Rousi, M. Nissinen, H. Huhtala, Y. T. Konttinen, and I. Arnala. 2013. “No Evidence of Long-Term Benefits of Arthroscopicacromioplasty in the Treatment of Shoulder Impingement Syndrome: Five-Year Results of a Randomised Controlled Trial.” Bone and Joint Research 2 (7): 132–39. doi:10.1302/2046–3758.27.2000163.

16. Brox, Jens Ivar, Cecilie Piene Schrøder, Øystein Skare, Petter Mowinckel, and Olav Reikerås. 2017. “Author Response — sham Surgery versus Labral Repair or Biceps Tenodesis for Type II SLAP Lesions of the Shoulder: A Three-Armed Randomised Clinical Trial.” British Journal of Sports Medicine, bjsports-2017–098251. doi:10.1136/bjsports-2017–098251.

17. McElvany, Matthew D., Erik McGoldrick, Albert O. Gee, Moni Blazej Neradilek, and Frederick A. Matsen. 2015. “Rotator Cuff Repair.” The American Journal of Sports Medicine 43 (2). SAGE PublicationsSage CA: Los Angeles, CA: 491–500. doi:10.1177/0363546514529644.

18. Large Study of Arthroscopic Rotator Cuff Repair Reveals Some Surprises.

19. Beard et al. (2017). Arthroscopic Subacromial Decompression for Subacromial Shoulder Pain (Csaw): A Multicentre, Pragmatic, Parallel Group, Placebo-Controlled, Three-Group, Randomised Surgical Trial. The Lancet. 391, 329–38.

20. Schreurs et al. (2017). No Benefit of Arthroscopy in Subacromial Shoulder Pain. The Lancet. 6736 (17).21. “Unnecessary Shoulder Surgery on the Rise — BJSM Blog — Social Media’s Leading SEM Voice.”

Articles Of The Week September 22, 2019


A few months ago there was an article claiming that smartphones were making Millenials grow horns. Fortunately, they have realized their mistake and recanted on their claims.

“Science Journal Walks Back Claim That Smartphones Make Millennials Grow Horns” – Nsikan Akpan

I once had a patient come in for a few treatments on their shoulder and we had limited success as far as improvement. We later found out they had a labral tear and ended up having surgery. But, was this really necessary? Maybe not.

“Can You Treat A Labral Tear?” – Jon Cain

There are many factors that contribute to our individual pain experiences. As it turns out if someone is injured at work their education, compensation systems, perceived disability, and depression can all influence how long someones pain persists.

“What Dictates How Much Pain You Feel After An Injury” – Malcolm Hogg

Quite often NSAID’s are recommended to help with inflammation and pain relief when patients are dealing with an injury. But is this really the best course of action? The FDA has shown that NSAID use actually contributes to heart attacks and strokes, so while their use may be useful in the short term, long term use is not recommended.

“FDA Strengthens Warning That NSAID’S Increase Risk Of Heart Attack And Stroke” – Gregory Curfman MD

There has long been research showing the benefit of exercise with regard to depression, but does it work equally for everyone?Put simply: exercise helps prevent depression. Just because you exercise doesn’t mean you won’t ever become depressed, but it certainly reduces the chances that you will.

“Everything We Know About Exercise And Depression” – Brad Stulberg

Finger Reset After Dislocation

3 Weeks after a DIP Dislocation in a gymnastics injury, swelling, pain, and weakness remained in the PIP more than DIP of that digit. She was unable to grip or hang/swing on bars without pain. In order to restore threat free grip, compression plus lateral rotation held enabled full pain-free passive end range flexion of the PIP. For the DIP, which was also limited in flexion, end range repeated extension restored pain-free flexion. Just a little experimentation and you can easily find desensitizing repeated loading strategies. She was prescribed to do these resets hourly and gradually work on grip strength.

[UPDATE]: Just followed up, after 4 days of the reset and grip strengthening, she was able to complete a bars routine and prior she was unable to even hang from the bar. Swelling is down, but still present, and grip strengthening needs to continue.

Articles Of The Week September 15, 2019


This is an important topic, so important it’s a two-part series and both made our articles this week. Part one helps us understand managing someone dealing with this, boundaries, informed consent, our role, and proper communication. Give these a read!

“Working With Clients Who Have Experienced Assault Part 1” – Robert Libbey

In part 2, Robert helps us understand what to avoid, and what things could possibly be a trigger for a patient who has experienced assault. He also shows us why we should embrace the opportunity to help this population of people.

“Working With Clients Who Have Experienced Assault Part 2” – Robert Libbey

I think we have all had a patient come to us who was told by another practitioner they had to come in for weekly, biweekly, or some other range of appointments in order for the said practitioner to “heal” them. While this may work on some patients (and boost said practitioners ego and pocketbook), it turns out humility is probably a better way for us to get patients.

“Healer Syndrome” – Paul Ingraham

Most of us work and contractors in a clinic, some of us are clinic owners. However, the government has started cracking down on the way things are structured in some clinics which put both the owner and contractor at risk. This helps us understand the differences and what we need to consider for a clinic setup.

“Independent Contractor Or Employee? Common Mistakes In Massage Therapy Invite Government Scrutiny And Penalties” – Erin Jackson

I love this as it’s an analogy I use to explain to patients that pain doesn’t necessarily equate to tissue damage.

“I Slept On It Wrong” – Dean Disanjh

Articles Of The Week September 8, 2019

So many patients have heard things like “your pain is all in your head” because a doctor didn’t understand a tricky condition the person was dealing with. While “it’s all in your head” is a terrible way to communicate with a patient, there is a direct correlation between trauma and chronic diseases, so mental health certainly has an impact on our physial health.

“Can Trauma Cause Chronic Illness?” – Renee Fabian

As seen in the above article, mental health is extremely important to our well being. However, one population where this is often overlooked or forgotten about is professional athletes. But thankfully this is starting to change and the stigma around it is changing to an attitude of strenth, not weakness.

“Why It Matters That More Athletes Are Talking About Their Mental Health” – John Affleck

Unfortunately our profession is often linked to prostitution, in spite of the great work so many of you are doing. Because of this, it is really important for us to protect ourselves and each other. This is why sharing this article is important, as a protection for each other. No matter how you decide to have your business, make sure YOU are in charge of it and protect yourself accordingly.

“They’re Putting People At Risk: Sexual Misconduct, Harassment, And Inaction At Zeel, The Top Massage App” – Brian Merchant

I remember teachers in college telling me how I may get a patient one day who comes in strictly to experience human touch. Well, now more than ever this may be a prime reason people come to see you, and this puts us into a pretty important position.

“We’re Living In An Age Where People Have Forgotten The Importance Of Physical Touch” – Eva Jackson

I’ve always been a big fan of this lady and she’s back to blogging again. If you haven’t looked at her stuff, check out her blog all about patients living with pain. In this post she gives lots of links to different sites which can help you understand the patients perspective. I hope she gets back to blogging frequently again…thanks Jo.

“Reconnecting, The First MyCuppaJo Email In A While” – Joletta Belton

4 Instant Ways To Help Increase Shoulder Movement

It’s the most mobile, yes least stable joint in the body.

This makes for a joint that can sometimes be a bit confusing to treat, especially with the various diagnosis names and syndromes that are thrown around.

With names like frozen shoulder, rotator cuff tears, impingement syndrome, and various other scary-sounding titles, we quite often just need to help get the shoulder moving again.

Here are four of my favourite graded exposure/altered movements I use to help patients get their shoulder moving again.

This first one is a great way to help when a patient is having difficulty with shoulder flexion.

This one is a great way to help with shoulder extension.

Here’s one to use on your table to assist with abduction.

And finally, if you have a broomstick, a piece of dowel, or something similar in your clinic, here’s another way to help with shoulder abduction.


  • The biggest thing we want to do is instill confidence in our patients by showing how these movements are safe. 
  • Showing patients that a little discomfort is okay, and it’s not the same as pain.
  • Make the movements meaningful to patients so they will do them at home.
  • Do the movements before and after your treatment demonstrating to the patient how much improvement THEY have made.
  • Make it fun.