I was driving to my office the other day and heard a local orthopedic surgeon advertising for joint replacement surgeries. Joint replacement surgery is big business, but there are preventable measures out there – including chiropractic care.
The Scope of the Problem
There appears to be no end to the growth in joint replacement procedures. Consider these staggering statistics:
- By 2030, Medicare will spend an estimated $50 billion on joint replacement surgeries.1
- From 2000 to 2010, there was a 125 percent increase in total hip replacements.2
- By 2030, it's estimated that 11 million people will have undergone hip or knee replacements.3
There are about 700,000 total knee replacements performed every year and roughly 400,000 total hip replacements in the United States annually. These procedures only last about 20 years and often require follow-up surgery. The age at which patients are undergoing these procedures is also going down. According to a study released in 2018, the average age for a hip replacement is just under 65, and the average age for a knee replacement is 66. Again, these numbers are staggering.
Ignoring the Cause
As chiropractors, we are proficient in addressing the root cause of joint degradation and are in a position to reduce these surgeries from increasing exponentially. The majority of joint replacements are a direct result of Maggs Law: When the loading of a tissue exceeds the capacity of that tissue, compensatory physiological changes occur.
Nowhere in our health care system is abnormal loading of joints detected. Musculoskeletal care in the U.S. is based on symptomatology, it's reactive care, not the loading or overloading of joints, tendons or muscles. Therefore, no testing is done to detect these findings, which we know can be detected as early as 10 years of age. For middle- and high-school athletes, eyes, ears, nose and throat are the focus of preseason exams.
The musculoskeletal guidelines in this country still encourage us to take a NSAID for the many aches and pains we suffer. And if our back pain or shoulder pain gets worse, call our primary. This starts the cascade of events that takes significant time and costs tremendous health care dollars ... while never fixing the cause of the pain or educating an individual how to better care for themselves.
Visiting the primary leads to a referral to an orthopedist, who refers to a physical therapist who can't / doesn't take X-rays, utilize MRIs, or consider foot scans or custom orthotics. So, virtually no abnormal loading is ever detected or corrected, but time and money have been spent – and will be spent again with each recurring episode.
As long as this approach continues, we can't expect joint replacement numbers to go down. With the increase in obesity (patients who undergo joint replacement surgeries have an average BMI of 30.85), lack of conditioning, dominance of the medical model of care and consistency of chiropractors adjusting a small percentage of the population at any given time, how can we ever expect a reduction in these procedures?
The reality is, the public is using the wrong model and wrong doctors to care for our musculoskeletal systems. This means back pain, neck pain, hip pain, plantar fasciitis, knee pain, etc.
Value of the Biomechanical Exam
As mentioned earlier, inappropriate exams begin with youth sports. While the musculoskeletal system is the system at greatest risk in sports, this system is virtually ignored by the health care industry. A classic medical exam is performed, along with a scoliosis screening which satisfies any musculoskeletal interests.
People between the ages of 45-64 make up 43 percent of knee replacements.4 It's important to begin detecting biomechanical faults early. But there are many biomechanical abnormalities which can be detected at a young age that will become the precursors to ultimate joint replacements, and corrective measures can easily be taken to alter the ultimate outcome.
Foot pronation, increased Q angles of the knee, femoral head height difference seen on the standing X-ray, any form of pelvic rotation, sacral base angle, Ferguson's center of gravity line, anterior cervical gravity line, straightening of the normal cervical lordotic curve, misalignment of the atlas / axis, and restricted range of motion of any of the joints in the kinetic chain – all contribute to an acceleration of breakdown of the body.
The Solution to This Crisis
A thorough biomechanical exam must consist of a physical exam by someone trained in biomechanics. A chiropractor is the most qualified to perform such a test. A physical therapist could perform this physical exam, but they cannot perform biomechanical X-rays, which provide 70 percent of the information found. An osteopath or orthopedist would seem qualified, but they are not qualified at all, as they practice the medical model of care.
Everyone should have a biomechanical exam at an early age. In schools, in conjunction with the preseason medical exams, biomechanical exams need to be done. Annual physicals should also consist of biomechanical components; perhaps a patient should have to see both their primary and their chiropractor to satisfy this requirement. Once these tests are performed, a proactive effort needs to be made by all involved:
- Regular chiropractic care to ensure and maintain mobility in all the joints of the body
- Custom orthotics, as the foundation of the body must be symmetrical and strong
- Regular exercise and dietary awareness to keep weight under control and the cardiovascular system strong
With these guidelines in place, there would be hope that the joint replacement epidemic would reverse in numbers.
When Will Things Change?
In order to solve a problem, one must clearly define the problem. Until our health care system can admit we currently lack quality proactive musculoskeletal care, joint replacement surgeries will continue increasing. A total revamp is needed, and the chiropractic profession is the most qualified to be a major part of that solution.
We must master the biomechanical exam and realize the importance of biomechanical information found on standing X-rays. Remember, engineering 101 says any architectural structure must have a strong and symmetrical foundation (think custom orthotics), and any structure that is subjected to aging, gravity and stress needs maintenance care. Until we can admit these truths, the prevalence of and profits from joint replacements will likely continue to climb.
References
- Bumpass D, Nunley R. Assessing the value of a total joint replacement. Curr Rev Musculoskelet Med, 2012 Dec;5(4):274-282.
- Kremers H, Larson D, Crowson C, et al. Prevalence of total hip and knee replacement in the United States. J Bone Joint Surg (U.S.), 2015;97(17):1386-1397.
- Wolford ML, Palso K, Bercovitz A. Hospitalization for total hip replacement among inpatients aged 45 and over: United States, 2000–2010. NCHS Data Brief No. 186. National Center for Health Statistics, 2015.
- Annual Incidence of Common Musculoskeletal Procedures and Treatment. Department of Research & Scientific Affairs, American Academy of Orthopaedic Surgeons, March 2014.
Dr. Tim Maggs has been in private practice for 35 years and is the developer of The Structural Management® Program and The Concerned Parents of Young Athlete's® Program. He travels the country teaching his program Biomechanics, Imaging and Care of the High School Athlete. For more information, visit www.CPOYA.com.