Chapter 2 Evolution Doesn't Move Backwards

It's what you learn after you know it all that counts. ~ John Wooden

In 2014 the costs of musculoskeletal disorders (MSD), including treatment and lost wages, represented 5.76% of GDP or $980 billion, exceeding defense spending for that year.

~ The Burden of Musculoskeletal Diseases in The United States 2014

Born with an anomaly where the “cure” involved pediatric surgery and the future promised continued discomfort and inevitable hip replacements, I had a head start in joining the population of those suffering from a musculoskeletal dysfunction or disorder (MSDs). And yet, I have not. Meanwhile, most people are not born predisposed to developing MSDs, but by 2015, more than half of American adults had one. Perhaps not surprisingly, the Burden of Musculoskeletal Diseases in the United States reported in 2014 that: “Back pain often originates from sources that are not readily identifiable. Many causes of back pain are likely related to degenerative changes, but the actual underlying cause of a given back pain episode is often uncertain.” Translation: We don’t know why.

In February 2021 and July 2022, The World Health Organization reported that:

• Musculoskeletal conditions and injuries are not just conditions of older age; they are prevalent across the life course.

• Musculoskeletal conditions are commonly linked with depression and increase the risk of developing other chronic health conditions.

Meanwhile, due to current medicine’s focus on specialization, point of pain rather than using a systemic approach, the immensity of the human and economic cost of MSDs is rarely captured. The numbers often leave out tangential costs, including contributing factors and side effects such as gastrointestinal (GI) complications due to the almost 100 million prescriptions of Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) issued each year, not to mention the over-the-counter versions. They also don’t reflect the broader impact of opioid and narcotic use, including addiction. All of these numbers are related and expected to escalate annually. The highly respected Phillip Pizzo, MD, of Stanford University School of Medicine, explains, "We see that for many patients, chronic physical pain becomes a disease in its own right… We need to address this in a more comprehensive and interdisciplinary way and include prevention as a very important goal…”.

By age 40, over a quarter of Americans seek medical help for Osteoarthritis (OA) of the knees and hips. The percentage increases to 38.6% by age 50, and by the time Americans are 60 years old, 62.2% are affected. Seeking to understand the cause or contributing factors, Ian Wallace, a postdoctoral fellow in paleoanthropology at Harvard, observed knee osteoarthritis using 2000 skeletons spanning over 6000 years. He went into the study hoping to find a straightforward answer to one piece of the puzzle. Instead, in August 2017, his team’s investigations showed for the first time that, “…knee osteoarthritis, a pervasive cause of pain, is actually twice as common today than even in the recent past. But the even bigger surprise is that it’s not just because people are living longer or getting fatter, but for other reasons likely related to our modern environments… It points to this mysterious conclusion: A lot of cases of osteoarthritis, which we thought might be inevitable, may be preventable… and are due to unknown factors… what this study shows is that there’s something else we’re missing.”

Dr. Wallace believes that a lack of physical activity could be that “unknown” since sitting while working dramatically increased after the 1950s. However, occupational sitting has been an issue for well over a century, perceived as the thinking man’s disease. Dr. David Felson, the study’s co-author, a physician at Boston University and renowned arthritis expert, supports this conclusion too, commenting, “Our joints don’t do well when they aren’t active much of the time… I study this, and I don’t know… what [more] can be done to prevent it … For now, your best bet is to keep a healthy diet and be physically active.”

With all due respect to Dr. Felson and Dr. Wallace, a healthy diet and being physically active cannot be the missing link. If it were that simple, then active soldiers in the United States Army, comprised of individuals free from obesity and sedentary behavior, would not report that “non-combat related musculoskeletal conditions account for over half of all disabilities… Knee and back injuries constitute a significant proportion of disability and limited duty …” And, “training injuries, treated on an outpatient basis, along with sports injuries may have the biggest impact on readiness.”

Although I agree with Dr. Felson that a healthy diet is important for musculoskeletal health and that joints need to move, we must accept the fact that all movement is not created equally. If we want to change the outcome, we must change our approach. We are in desperate need of a more holistic conversation emphasizing details, self-awareness, and empowerment. The correlation between our posture/movement and our musculoskeletal health is as fundamental as the now-accepted correlation between nutrition and disease. MRI technology and surgery have revealed the intricacies of our anatomy. Yet the statistics show we don’t just misunderstand pain, we’ve misjudged our ability to prevent it.

Meanwhile, fitness culture offers a false sense of security. If the US Army isn’t immune, what hope do civilians have, especially those following generic advice about “staying active”? When we want to improve our fitness, we often look to magazines, books, television, YouTube, social media, apps, websites, and blogs for examples of fit bodies and guidance for achieving one. We look at the pictures, read the brief descriptions, and watch the videos, doing our best to replicate what we see and are advised to do. Sometimes, we join classes, hire trainers, or go to physical therapy to ensure we get it right, trusting that our teachers and their methods are optimal. What details they overlook, we overlook as well. We are directed to what is deemed important through performance, observation, and omission. We’re trying, but despite all the effort and an enormous amount of educated, well-intentioned, and personalized advice available, pain and intervention statistics prove that we are missing the mark. We have created a culture of fitness that supports healthful goals such as improved overall health, weight loss, muscle tone, and agility for sports, that also promotes long-term consequences no one asked for: damaged joints, compressed spines, muscular imbalance, and pain, too often misattributed to aging.

Years ago, a doctor friend offered an anecdote that has stuck with me. His favorite teacher from medical school, speaking to a group of future doctors, advised, “It is imperative to remember that the practice of medicine is a very young science, so everything you are learning now could be wrong, but it is, with our experience so far, what we believe to be true, right now.” As his teacher recognized, medicine and science begin with observation. The more observations made and studies conducted, the greater the experience, the more we learn. Still, rarely can all meaningful variables be captured. So we have historically accepted some ideas as fact until reasons arise that cause us to reconsider our position. This begs the question: Is the musculoskeletal epidemic rooted in underestimating the impact of often overlooked factors typically dismissed as insignificant?

When the 90s arrived, I was introduced to Pilates. Navigating this ballet-infused world with legs that couldn’t turn out really opened my eyes to how assumed uniformity shapes the way bodies are approached. When you can move about unconsciously, the significance of your body’s details and their impact can easily remain invisible. There is no reason to address what you don’t see. If nothing hurts, the assumption is that all is well. But growing up, if I didn’t pay attention to how I moved, there were consequences. So I practiced noticing, which led to exploring the minutia in movement, offering insight into how we have hijacked our innate operating systems. I used my hands to feel what was hidden underneath what my eyes saw. As the child and grandchild of mechanical engineers, what I considered working backward, they called reverse engineering. Once you understand the underlying design principles, inefficiencies become apparent, and tools for mitigation, alleviation, or altogether avoidance simply present themselves. Just as standing can be accomplished with various muscle combinations and skeletal positioning, so can every other thing we do. A movement can appear roughly the same on the outside while masking different internal engineering. That realization planted the seed for a deeper theory, one I’m sure I share with others: pain without disease isn’t mysterious at all.

I believe that joint and spine pain, without disease, is rooted in foundational dysfunction. In other words, along the way, we got the basics wrong, spent decades building on that base, and it is failing. Humans did not come with manuals explaining ideal eating habits, optimal parenting, or the best way to inhabit our bodies because we didn’t need them. We ate what was available in nature, allowed our bodies to move in nature, and supported our children’s bodies to evolve within nature’s structure and timeline. Our movement systems were built to function efficiently without conscious input. But as humankind evolved, so did the world we inhabited and the way we inhabited the world. With all the available literature on parenting, eating, and movement, seemingly, the further we move away from a “natural” existence, the more guidance we require. We created extraordinary inventions to make life easier and accommodate changing priorities. Unfortunately, we’re often brilliant at innovation, but not as skilled at recognizing or addressing the unintended consequences.

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Do you have non-disease-related pain in your joints or spine that has become normalized? What advice were you offered? Please share in the comments! XxD

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Dropped in mid-journey? Walk Straight is best experienced from the beginning …