Weekly Literature Review: MSK & CHRONIC DISEASE

Curated for MSk Professionals, clinical leaders, payers & health system executives

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MONDAY | June 7, 2026

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The Invisible Crisis: Chronic Pain’s $296B Drag on the U.S. Economy

For: PT Clinicians | Clinical Leaders | Payers | Health System Executives

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THE HOOK

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One in five American adults wakes up every day in pain. Not acute, post-surgical pain-the kind that heals. Chronic pain: persistent, poorly managed, and quietly draining the U.S. economy of nearly $300 billion a year in lost wages and productivity. Yet the most evidence-backed interventions remain dramatically underutilized. That gap is not a clinical failure. It is a systems failure-and it sits squarely on the strategic agenda of every health system leader and payer today.

Key Stats:

• Adults with Chronic Pain: 50.2 million (20.5%)

• High-Impact Chronic Pain: 24.4 million (10%)

• Annual Economic Burden: ~$296 billion

Source: Yong, Mullins & Bhattacharyya (2022). Prevalence of chronic pain among adults in the United States. PAIN, 163(2), e328–e332.

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WHAT THE EVIDENCE ACTUALLY SHOWS

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Who Is Affected

• 20.5% of U.S. adults-more than 50 million people-experience chronic pain (pain on most or every day).

• 10% meet criteria for high-impact chronic pain, meaning pain that limits life or work activities on a regular basis.

• Back pain and lower-extremity pain (hips, knees, feet) dominate, with 40.9% and 44.1%, respectively, reporting being “bothered a lot.”

The Treatment Paradox

Physical therapy (18.6%) and massage (17.6%) lead all management strategies. Yet psychological therapies-with the strongest evidence base in chronic pain-remain startlingly underused:

• Talk therapy (CBT and related): 1.9%

• Self-management programs: 2.6%

• Peer support groups: 0.9%

“Despite strong evidence for cognitive behavioral therapy in chronic pain management, utilization remains well below 5%-a figure that should concern every clinical leader designing care pathways.”

Functional and Workforce Impact

Functional Domain | Chronic Pain | No Pain

Workdays missed/year | 10.3 | 2.8

Difficulty doing errands | 21.5% | 4.9%

Difficulty with social activities | 25.4% | 5.7%

Work limited by health | 48.8% | 15.0%

The Economic Arithmetic

• $79.9 billion in direct lost wages.

• $216 billion in broader GDP loss.

• ~$296 billion total annual economic impact-consistent with prior estimates of $299–$335 billion.

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CLINICAL LOGIC MEETS OPERATIONAL REALITY

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The biopsychosocial model of pain is not new-but its adoption in clinical care pathways remains uneven. Health systems that continue to default to pharmacologic-first or imaging-first approaches for chronic MSK pain face a compounding problem: high utilization, poor outcomes, and escalating downstream costs.

Physical therapy-already the most-used non-pharmacologic intervention at 18.6%-has a clear role in first-line chronic pain management. The operational argument is straightforward: PTs with training in pain neuroscience education (PNE) and interdisciplinary care coordination can address both the physical and psychosocial drivers of high-impact chronic pain. The challenge is building the referral infrastructure and reimbursement scaffolding to support that pathway at scale.

For payers: every percentage point reduction in high-impact chronic pain prevalence translates to measurable decreases in emergency utilization, imaging spend, and opioid prescribing rates.

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STRATEGIC TAKEAWAY

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For health system leaders and payers, the evidence here points to three actionable priorities:

• Expand access to interdisciplinary pain programs. Co-locate PT, behavioral health, and pain psychology within MSK care pathways-not as referral afterthoughts, but as first-line options.

• Invest in PNE-trained clinicians. Physical therapists trained in pain neuroscience education represent the highest-value touchpoint between clinical evidence and patient behavior change.

• Build payer-aligned outcome metrics. Workdays missed, functional limitation rates, and opioid prescribing are measurable proxies for chronic pain burden. Tie them to value-based care contracts.

The chronic pain crisis will not resolve itself. But it is solvable-with the right clinical infrastructure, payment models, and workforce strategy.

Citation: Yong, R. J., Mullins, P. M., & Bhattacharyya, N. (2022). Prevalence of chronic pain among adults in the United States. PAIN, 163(2), e328–e332. https://doi.org/10.1097/j.pain.0000000000002291

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TUESDAY | June 10, 2025

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Rural Orthopedics: When the Surgeon Is 200 Miles Away

For: PT Clinicians | Clinical Leaders | Payers | Health System Executives

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THE HOOK

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Only 9% of U.S. orthopedic surgeons practice in rural areas-yet those communities represent nearly 20% of the population. When a rural patient fractures a hip or tears an ACL, the gap between them and surgical care is not just measured in miles. It is measured in delayed diagnoses, missed follow-ups, inadequate rehabilitation, and worse outcomes. This is not an abstract equity concern. For health systems operating rural or community facilities, it is a direct patient safety and financial risk.

Key Stats:

• Rural Orthopedic Surgeons: 9% of total

• Rural Share of U.S. Population: ~20%

• Rural Hospital Ortho Coverage: Only 30%

Source: Hasan & Kayum (2024). Patient experience and satisfaction with orthopedic services at a community (rural) setting hospital. Journal of Market Access & Health Policy, 12, 209–215.

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MAIN FINDINGS AT A GLANCE

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> Rural access barriers drive delays and poorer follow-up.

> Quality and resources are consistently lower in rural hospitals.

> Rural populations carry higher medical complexity and risk.

> Personalized care is a real strength-but cannot offset structural gaps.

> Collective system-level disparities worsen experience and satisfaction.

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THE CLINICAL AND OPERATIONAL PICTURE

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Access: The First Barrier

Rural patients face a compounding set of access challenges: long travel distances to orthopedic specialists, limited broadband undermining telehealth adoption, and a paucity of subspecialty coverage (pediatric, geriatric, complex spinal). When only 30% of rural hospitals have an orthopedic surgeon on staff, elective and urgent cases alike face delays that directly affect outcomes-particularly in time-sensitive scenarios such as hip fractures in older adults.

Resource Reality

Beyond surgeon availability, rural hospitals frequently operate with shortages of anesthesiology coverage, appropriate implant inventory, wound care services, and outpatient therapy capacity. These are not edge cases-they are the structural baseline for a significant portion of the rural hospital footprint. Post-acute rehabilitation, already a bottleneck nationally, is even more constrained in rural settings.

Population Complexity

Rural populations also present with higher burdens of chronic disease, obesity, and aging demographics. This is not a volume problem-it is a complexity problem. The patients most likely to need orthopedic care are also the most likely to face barriers accessing it, and the most likely to have comorbidities that complicate surgical candidacy and recovery.

“The personalized physician–patient relationship that characterizes rural care is a genuine asset-but it cannot substitute for subspecialty access, surgical infrastructure, or post-acute rehabilitation capacity.”

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WHAT WORKS: EVIDENCE-BASED SOLUTIONS

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• Visiting consultant clinics and hub-and-spoke orthopedic models

• Telehealth-enabled post-operative follow-up and PT delivery

• Regional partnerships between rural and urban tertiary centers

• Transportation coordination integrated into the care pathway

• Community health worker programs for chronic disease co-management

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STRATEGIC TAKEAWAY

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Rural orthopedic access is a convergence point for value-based care, equity strategy, and patient safety. Health systems with rural footprints should prioritize three moves:

• Audit rural orthopedic coverage gaps and map them against patient outcome and readmission data.

• Build telehealth-enabled PT pathways that extend post-surgical rehabilitation reach without requiring travel.

• Negotiate value-based contracts that account for rural complexity-flat fee-for-service models systematically undervalue care delivered in high-barrier environments.

Citation: Hasan, K., & Kayum, S. (2024). Patient experience and satisfaction with orthopedic services at a community (rural) setting hospital-How is it different from an urban setting? Journal of Market Access & Health Policy, 12, 209–215. https://doi.org/10.3390/jmahp12030017

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WEDNESDAY | June 11, 2025

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Depression Is a Musculoskeletal Problem: The $334B Evidence.

For: PT Clinicians | Clinical Leaders | Payers | Behavioral Health Strategists

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THE HOOK

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Major depressive disorder cost the U.S. $333.7 billion in 2019-and nearly two-thirds of that burden had nothing to do with healthcare. It lived in workplaces, households, and communities: missed workdays, reduced productivity, caregiver disruption, and premature mortality. For physical therapists and MSK leaders, this is not tangential. Depression is one of the most powerful predictors of chronic pain persistence, surgical outcome failure, and rehabilitation non-compliance. Ignoring it in the clinical pathway is not neutral. It is costly.

Key Stats:

• Total Economic Burden (2019): $333.7 billion

• Indirect Costs: 62% of total

• Household Spillover Costs: $80.1 billion

Source: Greenberg et al. (2023). The economic burden of adults with major depressive disorder in the United States (2019). Advances in Therapy, 40, 4460–4479.

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BREAKING DOWN THE $334B

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Cost Category | Annual Estimate

Direct healthcare costs | $127.3 billion (38.1%)

Presenteeism (reduced productivity) | $43.3 billion

Absenteeism (missed workdays) | $38.4 billion

Household-related disruption | $80.1 billion

Unemployment | $30.3 billion

Premature mortality | $9.6 billion

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WHY THIS MATTERS FOR MSK CLINICIANS

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The clinical overlap between depression and chronic musculoskeletal pain is well-established. Patients with comorbid depression and MSK conditions show:

• Longer recovery timelines post-surgery and post-rehabilitation

• Higher rates of opioid dependence and misuse

• Lower adherence to home exercise programs

• Greater utilization of emergency and urgent care services

The implication for PT clinical design is direct: screening for depression as a routine part of the MSK intake-using validated tools such as the PHQ-2 or PHQ-9-is not scope creep. It is evidence-based triage.

“The incremental healthcare cost per adult with MDD was $6,429 annually-but the household spillover cost ($80.1 billion) suggests the real burden extends well beyond the patient in the room.”

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THE WORKFORCE AND PRODUCTIVITY ANGLE

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For employers and payers designing employee health benefit strategies, the productivity numbers are stark. Workers with MDD missed an excess of 9–14 workdays per year and experienced approximately 23 excess days of reduced productivity (presenteeism). Combined, that is roughly five weeks of annual performance degradation per affected employee.

A rapid-acting therapy achieving a 50% early response rate-compared to the 19.8% standard-of-care rate-was modeled to reduce the total economic burden by 7.7% over 12 months. The implication: treatment efficacy has direct and quantifiable financial returns.

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STRATEGIC TAKEAWAY

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• Embed behavioral health screening into MSK pathways. A PHQ-2 at intake costs minutes. Untreated depression costs months of recovery.

• Support interdisciplinary care team design. PTs, psychologists, and social workers functioning in coordinated care models are not a luxury-they reflect the evidence.

• Make the business case to payers. Depression treatment generates measurable ROI through reduced absenteeism, presenteeism, and downstream acute care utilization.

Citation: Greenberg, P., Chitnis, A., Louie, D., Suthoff, E., Chen, S.-Y., Maitland, J., Gagnon-Sanschagrin, P., Fournier, A.-A., & Kessler, R. C. (2023). The economic burden of adults with major depressive disorder in the United States (2019). Advances in Therapy, 40, 4460–4479. https://doi.org/10.1007/s12325-023-02622-x

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THURSDAY | June 12, 2025

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Chronic Disease Will Double by 2050: Is Your Health System Ready?

For: Clinical Leaders | Payers | Health System Executives | Public Health Strategists

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THE HOOK

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The number of U.S. adults aged 50 and older living with at least one chronic disease will nearly double by 2050-from 71.5 million to 142.7 million. Multimorbidity will surge by 91%. And the fastest-growing segment will be adults aged 80 and older, a population that will triple in size over the same period. These are not projections built on optimistic assumptions. They are outputs of a rigorous multi-state population model calibrated against 20 years of longitudinal data. For health system leaders, this is the strategic planning horizon.

Key Stats:

• Adults 50+ with Chronic Disease (2050): 142.7 million (+100%)

• Multimorbidity Growth: +91% by 2050

• Adults 80+: Growth of +137% by 2050

Source: Ansah & Chiu (2023). Projecting the chronic disease burden among the adult population in the United States using a multi-state population model. Frontiers in Public Health, 10, 1082183.

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UNDERSTANDING THE MODEL

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Ansah and Chiu (2023) used a dynamic multi-state population model to track transitions among three health states: healthy, one chronic condition, and multimorbidity (2+ conditions). Conditions included reflect the dominant drivers of MSK and whole-person health burden: hypertension, diabetes, cancer, coronary heart disease, heart failure, stroke, arthritis, and psychiatric problems.

The 20-year Health and Retirement Study dataset provides age-, gender-, and race-specific transition probabilities-lending the projections a level of epidemiological granularity that cruder models lack.

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THE DEMOGRAPHICS THAT DRIVE STRATEGY

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Age

Adults aged 60–79 currently hold approximately 60% of all chronic disease cases and will continue to do so through 2050. But the growth rate among adults 80+ is where the real planning pressure lives: a 244% increase in adults with at least one chronic condition, and a 203% increase in multimorbidity. These are the patients who will fill skilled nursing facilities, drive home health utilization, and demand geriatric-specialized care at volumes the current workforce is not equipped to handle.

Race and Ethnicity

By 2050, chronic disease prevalence will converge across racial groups-reaching roughly 64% among non-Hispanic whites, 61% among non-Hispanic Black adults, and 64.5% among Hispanic and other populations. However, Hispanic adults will see the steepest absolute growth (+109.6%), driven both by population expansion and higher transition rates into multimorbidity. Health equity strategies cannot be deferred to 2040.

Multimorbidity: The Clinical Complexity Multiplier

Multimorbidity is not simply two chronic diseases. It is an exponential increase in care complexity, polypharmacy risk, and the need for coordinated whole-person care. For MSK clinicians, the practical implication is direct: a patient presenting with knee osteoarthritis in 2050 will, on average, have at least one additional major chronic condition. Clinical pathways designed around single-condition episodes will be structurally inadequate.

“By 2050, nearly half of all U.S. adults aged 50 and older will carry at least one chronic disease. Designing care models for the average healthy adult is designing for the minority.”

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STRATEGIC TAKEAWAY

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• Workforce planning must account for geriatric and complex chronic care volume. PT programs, nursing schools, and GME pipelines are not currently calibrated for a 142-million-person chronic disease population. That misalignment starts compounding now.

• Whole-person care models are not aspirational-they are actuarial. Health systems that continue to operate single-condition episode-of-care models face structural financial risk as multimorbidity dominates their patient mix.

• Social determinants must be embedded in chronic disease management. The convergence of racial/ethnic burden projections masks persistent disparities in access, quality, and outcomes. Equity strategy is risk management.

Citation: Ansah, J. P., & Chiu, C.-T. (2023). Projecting the chronic disease burden among the adult population in the United States using a multi-state population model. Frontiers in Public Health, 10, 1082183. https://doi.org/10.3389/fpubh.2022.1082183

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FRIDAY | June 13, 2025

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Cardiovascular Disease Will Hit 45 Million Americans by 2050: What Rehab Medicine Must Do Now

For: PT Clinicians | Clinical Leaders | Payers | Health System Executives | Public Health Strategists

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THE HOOK

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The American Heart Association projects that cardiovascular disease and stroke will affect 45 million U.S. adults by 2050-up from 28 million today. Hypertension will climb from 51% to 61% of the adult population. Stroke prevalence will nearly double. And obesity-the upstream driver of most of these trends-will reach 60.6% of U.S. adults. For physical therapists and rehabilitation medicine leaders, this is not a cardiology problem to observe from the sidelines. It is the defining clinical and operational challenge of the next two decades.

Key Stats:

• CVD & Stroke Adults (2050): 45 million (up from 28M)

• Hypertension Prevalence: 61% by 2050

• Obesity Prevalence: 60.6% by 2050

Source: Joynt Maddox et al. (2024). Forecasting the burden of cardiovascular disease and stroke in the United States through 2050. Circulation, 150, e65–e88.

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WHAT’S RISING, WHAT’S FALLING

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Risk Factor | 2020 → 2050 Trend

Hypertension | 51.2% → 61.0% ↑

Diabetes | 16.3% → 26.8% ↑

Obesity | 43.1% → 60.6% ↑

Inadequate sleep | 40.3% → 42.1% ↑

Smoking | 15.8% → 8.4% ↓

Physical inactivity | 33.5% → 24.2% ↓

High cholesterol | 45.8% → 24.0% ↓

Improvements in smoking and physical inactivity reflect decades of public health investment. But obesity-now the dominant modifiable risk factor-is moving in the wrong direction. Sleep, newly recognized as one of Life's Essential 8 metrics, is worsening. These are the variables that will shape the cardiovascular rehabilitation caseload of 2035 and beyond.

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THE REHABILITATION IMPERATIVE

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Cardiac Rehabilitation: Still Underutilized

Despite Class I guideline endorsement, cardiac rehabilitation participation rates remain below 25% nationally. The AHA projections make this gap more urgent: with 45 million adults carrying CVD and stroke burden by mid-century, the argument for expanding cardiac rehab access-through telehealth, hybrid models, and insurance coverage parity-is both clinical and economic.

The Obesity-MSK-CVD Nexus

Obesity does not affect cardiovascular risk in isolation. The same adipose-driven inflammatory pathways that accelerate atherosclerosis also drive osteoarthritis, low back pain, and the risk of post-surgical complications. A patient with obesity presenting to a PT for knee pain in 2030 is, statistically, also hypertensive, pre-diabetic, and at elevated CVD risk. Treating the knee in isolation is both clinically incomplete and a missed opportunity for upstream intervention.

Disparities: The Widening Gap

The advisory is explicit: most adverse cardiovascular trends will be worse among American Indian/Alaska Native, multiracial, Black, and Hispanic populations. Black adults carry the highest current prevalence of hypertension, diabetes, and obesity. Hispanic and AI/AN populations show the steepest projected increases. These are not footnotes. They are the patient populations that will increasingly define the clinical caseload of health systems operating in diverse urban and rural markets.

“The advisory modeled two prevention scenarios: achieving Healthy People 2030 targets (10% risk factor reduction) and aggressive intervention (50% obesity reduction + doubled risk factor control). Both scenarios significantly reduce future CVD burden, underscoring that this trajectory is not fixed. It is a policy choice.”

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STRATEGIC TAKEAWAY

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• Expand cardiac rehab access now. Telehealth and hybrid models can close the participation gap before demand doubles.

• Treat obesity as the upstream variable. Weight management programs integrated into MSK and cardiac care pathways are not optional add-ons-they address the most prevalent and fastest-growing modifiable risk factor.

• Design for multimorbidity. CVD, diabetes, obesity, and MSK conditions co-occur at a population scale. Single-condition care pathways are already obsolete.

• Invest in sleep health. Inadequate sleep is the only life essential 8 metric projected to worsen. Behavioral sleep medicine is an underdeveloped component of most rehabilitation programs.

• Build equity into the clinical infrastructure. Disparities in CVD burden are projected to widen. Health systems that do not proactively address access and cultural competency will face both outcomes gaps and payer performance penalties.

The cardiovascular disease trajectory is alarming. It is also a planning opportunity. Health systems that begin redesigning their rehabilitation, chronic disease management, and prevention infrastructure now-rather than in 2040-will be positioned to lead on both outcomes and value-based performance.

Citation: Joynt Maddox, K. E., Elkind, M. S. V., Aparicio, H. J., Commodore-Mensah, Y., de Ferranti, S. D., Dowd, W. N., Hernandez, A. F., Khavjou, O., Michos, E. D., Palaniappan, L., Penko, J., Poudel, R., Roger, V. L., & Kazi, D. S. (2024). Forecasting the burden of cardiovascular disease and stroke in the United States through 2050. Circulation, 150, e65–e88.