The Economist Says Back and Shoulder Surgery Is Overused. Here Is Where I Agree, and Where I Don't

On September 24, 2026, The Economist ran a leader under the headline "Back and shoulder surgery is often worse than useless," with the subhead "Millions of operations should be scrapped." Its argument: "a growing body of evidence suggests millions of surgeries performed each year are unnecessary."

I am an osteopathic physician. I offer platelet-rich plasma (PRP) injections and osteopathic manipulative treatment (OMT), and I perform interventional pain procedures through Hartford HealthCare. I read the piece with a lot of agreement and one reservation. The evidence does show overuse of certain back and shoulder operations in certain groups of people. It does not show that surgery is the problem. The question worth asking is which option comes first, for which person.

What the Economist got right

The Economist was careful to say that plenty of surgery saves lives and that many operations make life better. It singles out three orthopedic procedures, carpal tunnel release and total knee and hip replacement, as clearly better than non-operative care. Its target is narrower: operations that trials have tested against placebo or conservative care and found wanting. It names lumbar-spine decompression among the procedures it says are no better than "drugs, physiotherapy or just Father Time," and it reports that a drop in shoulder-surgery referrals is saving England's National Health Service about £100 million a year.

The shoulder evidence behind that is strong.

• The CSAW trial (The Lancet, 2018, Beard and colleagues) randomized 313 people in the UK with subacromial shoulder pain to decompression surgery, arthroscopy only (a placebo operation with no bone removed), or no treatment. Decompression offered no extra benefit over the placebo operation. Both surgical groups did slightly better than no treatment, but the difference was not clinically important. The authors wrote that the findings question the value of the operation and should be shared with patients before they decide.
• The FIMPACT trial, five-year follow-up (British Journal of Sports Medicine, 2021, Paavola and colleagues), found that subacromial decompression gave no benefit over diagnostic arthroscopy, or over exercise therapy, at five years.
• A BMJ clinical practice guideline (2019, Vandvik and colleagues), written by a panel of patients, clinicians and methodologists, made a strong recommendation against subacromial decompression surgery for adults with shoulder pain.

On the spine side, the Lown Institute Hospitals Index (2025) counted more than 200,000 unnecessary back surgeries on Medicare patients over three years, costing Medicare more than $1.9 billion. On average, 13% of spinal fusions and laminectomies met its overuse criteria.

Where the line actually falls

The Lown definition is worth reading closely, because it shows where overuse ends. It counted a fusion or laminectomy as overuse when it was done for low back pain in someone with none of the following: radicular symptoms, trauma, a herniated disc, discitis, myelopathy, radiculopathy or scoliosis. In other words, the concern is surgery for back pain alone, in a spine without a clear structural or nerve problem to fix.

That is also where I would put the line. Surgery can be the right call, and sometimes the only one:

• Fractures and other trauma.
• Nerve compression with weakness that is getting worse.
• Loss of bladder or bowel control with back pain. This is an emergency. Go to an emergency department now, not a consult.
• A spine or joint that a surgeon judges structurally unstable.

If you have sudden weakness or any change in bladder or bowel function, seek emergency care today.

The order-of-operations argument

Here is my position, stated plainly. Before an elective back or shoulder operation done for pain, consider lower-risk options such as OMT and PRP. I say this even to people who have already done physical therapy and had injections that did not help, because OMT and PRP are different treatments from the ones that failed.

This is an argument about sequence and risk. It is not a promise. OMT and PRP do not work for everyone, and the evidence behind both is mixed. What they share is a much lower risk than an operation.

OMT: what it is and what the evidence says

Osteopathic manipulative treatment is hands-on care that uses stretching, gentle pressure and positioning to improve how joints and soft tissue move. It starts with a structural exam, which sometimes turns up a contributor nobody treated, such as a pelvic obliquity feeding low back pain.

The research is honest about its limits. A randomized trial in Spine (2003, Licciardone and colleagues) found that OMT and sham manipulation both appeared to provide some benefit when added to usual care for chronic low back pain. The authors said it remained unclear how much came from the techniques themselves and how much from other parts of the visit, such as range-of-motion work or time spent with the physician.

Guidelines still put this kind of care first. The American College of Physicians (Annals of Internal Medicine, 2017) issued a strong recommendation that people with chronic low back pain start with nonpharmacologic treatment, a list that includes exercise, multidisciplinary rehabilitation, acupuncture, mindfulness, yoga and spinal manipulation. It rated the evidence for spinal manipulation as low quality, and recommended starting there anyway. You can read more about how we use osteopathic medicine.

PRP: a different injection from the one that failed

PRP is made from a small sample of your own blood, concentrated so the platelets are delivered to the injured tendon or joint. A cortisone shot works differently: it is a steroid that calms inflammation.

The comparison between the two is mixed. PRP tends to hold up longer over time, while cortisone can bring faster relief in the first several weeks. So a cortisone shot that wore off tells you how cortisone worked for you. It does not answer whether PRP will, because it is a different treatment. We cover this in more detail in PRP vs cortisone, and for the shoulder specifically in PRP for rotator cuff tears.

Questions to ask before you say yes to surgery

The Economist ends by calling for "shared decision-making," where the surgeon lays out a range of options and the patient chooses with them. I agree. These are the questions I would bring to that conversation:

1. What is the pain generator? Imaging findings and pain do not always line up, so ask how the surgeon connected the two.
2. What exactly was tried already? A handout of home exercises and a structured, progressive physical therapy program are not the same thing.
3. What is the expected benefit, in numbers, and what is the chance of no improvement?
4. What are the risks and the recovery time?
5. What happens if I wait three to six months and try something with a different mechanism first?

If the answers point to surgery, good. You made the decision with the full picture.

This article is for education and is not medical advice. It does not replace an evaluation by a physician who knows your history.