Weekly Literature Review: MSK Injury Assessment, Trajectories, and Recovery

Happy New Year!

Monday: Trajectory-Based Phenotyping After Acute MSK Trauma

Main Points

• Three distinct pain interference trajectories emerged after non-catastrophic MSK trauma: rapid recovery (32%), delayed recovery (27%), and minimal/no recovery (41%)

• Two pain severity trajectories identified: rapid recovery (81%) and minimal/no recovery (19%)

• Axial injuries (head, neck, low back) were the strongest predictors of poor recovery across both outcomes

• Female sex predicted poor recovery for pain interference but not pain severity

• Pain interference revealed more nuanced recovery patterns than pain severity alone, identifying a "delayed recovery" group missed by severity measures

• Predictive accuracy: 74% for interference trajectories, 81% for severity trajectories

Clinical Significance

Early identification of high-risk patients (female sex, axial injury) enables targeted interventions and supports mechanism-based care rather than generic "wait and see" approaches.

Citation

Lee, J. Y., Walton, D. M., Tremblay, P., May, C., Millard, W., Elliott, J. M., & MacDermid, J. C. (2020). Defining pain and interference recovery trajectories after acute non-catastrophic musculoskeletal trauma through growth mixture modeling. BMC Musculoskeletal Disorders, 21(615). https://doi.org/10.1186/s12891-020-03621-7

Tuesday: Demographics Don't Predict Early Recovery Satisfaction

Main Points

• No demographic or baseline variables predicted satisfaction with recovery in the early phase (<30 days) after non-catastrophic MSK injuries

• Study tested 13 variables including age, sex, education, employment, injury type, body part, and mechanism of injury

• All regression coefficients were non-significant in multivariable modeling

• Findings suggest satisfaction is shaped by psychological, social, or contextual factors rather than patient demographics

• Results challenge clinicians to look beyond "who the patient is" toward modifiable factors

Clinical Significance

Clinicians should focus on patient education, communication quality, expectation management, and early psychosocial support rather than relying on demographic profiles to identify at-risk patients.

Citation

Maleki, M., & Modarresi, S. (2025). Investigating the association between demographic factors and patient satisfaction with recovery in the early phase after non-catastrophic musculoskeletal injuries: A cross-sectional study. BMC Research Notes, 18(175). https://doi.org/10.1186/s13104-025-07210-6

Wednesday: Large-Scale PT Trajectory Analysis Reveals Three Distinct Paths

Main Points

• Analysis of 597,245 patients across 900+ clinics identified three disability trajectories after initiating outpatient PT

• Significant gradual improvement (61.4%): steady recovery over ~3 months

• Minimal change (35.2%): little to no improvement over 6 months, slight trend toward worsening

• Significant immediate worsening (3.4%): rapid decline within first 2 weeks

• Trajectories were consistent across body regions (spine, upper extremity, lower extremity)

• Strongest predictors of poor trajectories: lower baseline physical health (PCS), lower mental health (MCS), higher Social Deprivation Index, certain insurance types, older age, and higher comorbidity burden

• Mental and physical health status were among the most powerful predictors

Clinical Significance

One-third of PT patients show minimal benefit from standard care pathways. Early identification of high-risk patients could enable tailored interventions, psychosocial screening, social risk mitigation, and earlier escalation or alternative treatments.

Citation

Lentz, T. A., Ikeaba, U., Alhanti, B., Lutz, A., George, S. Z., Cook, C., & Thigpen, C. (2025). Self-reported disability trajectories and their predictors among patients receiving care by physical therapists for musculoskeletal conditions: A retrospective analysis of registry data. BMJ Open, 15, e099315. https://doi.org/10.1136/bmjopen-2025-099315

Thursday: Operative vs. Nonoperative Rotator Cuff Recovery Timelines

Main Points

• Nonoperative care produces faster early improvement: By 3.25 months, 40% of PT patients achieved MCID in SPADI vs. only 6% of surgical patients

• Surgery produces greater long-term improvement: By 15.5–24.7 months, surgical patients showed significantly higher rates of >50% improvement (96% vs. 66% for ASES at 24.7 months)

• Recovery curves cross over around 12–18 months, with PT favoring speed and surgery favoring magnitude

• Study included 169 patients (96 nonoperative, 73 surgical) with propensity score weighting

• Early postoperative morbidity explains the delayed surgical benefit

Clinical Significance

This evidence is critical for shared decision-making and expectation-setting. Patients prioritizing early return to function may benefit from PT, while those seeking maximal long-term improvement (especially with full-thickness tears) may benefit from surgery. The "wait and see" approach may be appropriate given the favorable early PT trajectory.

Citation

Song, A., DeClercq, J., Ayers, G. D., Higgins, L. D., Kuhn, J. E., Baumgarten, K. M., Matzkin, E., & Jain, N. B. (2020). Comparative time to improvement in nonoperative and operative treatment of rotator cuff tears. Journal of Bone and Joint Surgery, 102(13), 1142–1150. https://doi.org/10.2106/JBJS.19.01112

Friday: Team Physician Consensus on Initial MSK Injury Management

Main Points

• 2024 consensus statement from six major U.S. sports medicine organizations provides evidence-informed guidance for initial assessment and management of common MSK injuries

• Core themes across injury domains: workload management, kinetic chain conditioning, and early decision-making shape long-term outcomes

• Shoulder dislocation: high recurrence in young athletes (up to 92%), early relocation and neurovascular assessment critical

• Disabled throwing shoulder (DTS): kinetic chain–driven condition requiring hip/core/scapular assessment and workload modification

• UCL tears: rising incidence in youth throwers, linked to kinetic chain deficits and workload spikes

• ACL injury: multimodal neuromuscular training reduces incidence; surgery indicated for instability, pivoting sports, or prevention of secondary injury

• Hamstring injury: most common non-contact muscle injury; prevention via neuromuscular programs and eccentric strengthening

• Groin/hip pain: requires differentiation of extra-articular (adductor, iliopsoas, inguinal) vs. intra-articular (FAI) pathology

• Imaging principles: radiographs foundational, MRI/MRA/CT selective, ultrasound emerging

Clinical Significance

The first minutes, hours, and days after injury often determine long-term trajectory. Prevention programs work but remain underutilized. Workload management is a modifiable risk factor across multiple injury types.

Citation

Herring, S. A., Kibler, W. B., Putukian, M., Boyajian-O'Neill, L. A., Chang, C. J., Franks, R. R., Hutchinson, M., Indelicato, P. A., O'Connor, F. G., Powell, A., Roach, R., Safran, M., Statuta, S. M., & Sutton, K. (2024). Initial assessment and management of select musculoskeletal injuries: A team physician consensus statement. Medicine & Science in Sports & Exercise, 56(3), 385–401. https://doi.org/10.1249/MSS.0000000000003324

🎯 Weekly Themes & Strategic Insights

1. Trajectory-Based Phenotyping Is the Future of MSK Care

Three studies this week (Lee, Lentz, Song) demonstrate that recovery is not uniform. Distinct trajectories exist across pain, disability, and functional outcomes. Single time-point assessments miss critical early divergence patterns that predict long-term outcomes.

2. Biopsychosocial Factors Drive Outcomes More Than Demographics Alone

Mental health, physical health, social deprivation, and comorbidity burden consistently predicted poor trajectories (Lentz), while traditional demographics failed to predict satisfaction (Maleki). This reinforces the need for integrated, whole-person care models that address psychological and social barriers early.

3. Early Decisions Shape Long-Term Outcomes

Whether it's identifying high-risk patients within weeks (Lee), recognizing minimal responders to PT (Lentz), choosing between operative and nonoperative rotator cuff care (Song), or managing on-field injuries correctly (Herring), the initial assessment and early management phase is the most powerful intervention window.

4. Workload and Kinetic Chain Are Modifiable Risk Factors

Across shoulder, elbow, hip, knee, and muscle injuries, the consensus statement (Herring) highlights workload management and kinetic chain conditioning as evidence-based, actionable strategies that reduce injury risk and improve recovery.

5. One-Third of Patients Don't Respond to Standard Care

The Lentz study's finding that 35% of PT patients show minimal improvement over 6 months is a call to action. Standard pathways don't work for everyone. Precision medicine, early phenotyping, and alternative interventions are needed for this substantial subgroup.

6. Speed vs. Magnitude Trade-Offs Matter

The Song study elegantly demonstrates that recovery timelines differ by treatment choice. PT offers faster early relief; surgery offers greater long-term improvement. This nuance is essential for shared decision-making and aligning treatment with patient goals, timelines, and functional demands.

Implications for MSK Care Delivery, Technology, and Strategy

• Risk stratification tools should incorporate mental health, social determinants, and functional interference measures—not just pain severity or anatomical diagnosis

• Early phenotyping (within 2–4 weeks) could enable tailored pathways for high-risk patients before chronicity sets in

• Trajectory monitoring should replace episodic outcome measurement in PT and recovery programs

• Shared decision-making frameworks must incorporate speed-vs-magnitude trade-offs, especially for rotator cuff, ACL, and other conditions with both surgical and conservative options

• Prevention programs (ACL, hamstring, workload management) remain underutilized despite strong evidence

• Psychosocial screening should be embedded early in MSK care pathways, not reserved for chronic or "failed" cases

Bottom line: This week's literature reinforces a shift from anatomical diagnosis and generic protocols toward trajectory-based, biopsychosocially informed, early-phenotyped MSK care that recognizes recovery is neither linear nor uniform.