Crooked: Outwitting the Back Pain Industry, Book Review

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What if much of what you’ve been told about treating back pain is wrong — and profitable for someone else? That question sits at the heart of Cathryn Jakobsen Ramin’s investigation into the back pain industry, a multi-billion-dollar enterprise she argues may be doing more harm than good for millions of people with chronic back pain.

As practitioners who work daily with people frustrated by failed back pain treatments, we approached Crooked with professional curiosity. Ramin’s reporting validates concerns we see in practice: people who have undergone multiple failed surgeries, people trapped in cycles of dependency on medications or injections, and people who have spent thousands on treatments that address symptoms while ignoring root causes.

In this review we look at what Ramin gets right about systemic problems in back pain treatment, where her critique aligns with our whole-body approach, and where a book necessarily stops short of what an assessment can do.

About the book: an industry exposé

Cathryn Ramin is a seasoned health and science journalist. What makes Crooked particularly compelling is that her investigation began with her own frustrating experience of chronic back pain and the contradictory treatment advice she received.

At its core, Crooked argues that the back pain industry has become profit-driven in ways that often prioritise revenue over patient outcomes. Ramin documents how financial incentives shape treatment recommendations, from unnecessary MRIs and injections to surgeries with questionable supporting evidence. She describes how the medicalization of back pain has created enormous profits while failing to improve outcomes for most patients.

The book is a useful check for anyone considering surgery or aggressive intervention, giving evidence-based reasons to question recommendations and ask about alternatives.

What Ramin gets right

The over-treatment problem

Ramin’s most compelling contribution is her documentation of systematic over-treatment in back pain care. She presents statistics showing the United States performs far more back surgeries than other developed nations, without better outcomes.

We see this pattern regularly. Clients arrive with MRI reports showing bulging discs or stenosis, having been told they need surgery. Yet when we assess their movement patterns and posture, we often find the pain stems from muscle imbalances and compensatory patterns that have little to do with the structural findings on the MRI.

Surgery as a profit centre

Ramin’s most pointed findings concern spinal fusion surgery, which she argues is often motivated more by profit than patient benefit. She documents how this lucrative procedure is frequently recommended despite evidence showing outcomes no better than conservative treatment for most conditions.

We regularly work with people recovering from failed back surgeries who wish they had been fully informed about success rates, complication risks, and the evidence for conservative alternatives first.

The power of movement and exercise

Where the investigation is strongest is in highlighting evidence for exercise and movement-based approaches. Ramin presents research showing targeted exercise often outperforms surgery, injections and other aggressive interventions for chronic back pain.

That emphasis on active recovery is the foundation of our posture therapy approach. When people understand their specific postural imbalances and learn exercises built around them, they can achieve relief that passive treatments never provided.

Where journalism meets clinical practice

While Ramin’s work exposes the problems well, there is an inevitable gap between identifying what is wrong and providing specific solutions. Readers finishing Crooked often face a practical question: now what? They understand they should question unnecessary surgery and favour movement-based approaches, but they still need to identify their own specific problem.

That is where assessment matters. A book can tell you exercise generally works better than surgery; it cannot assess your particular postural imbalances, identify which muscles are dysfunctional versus compensating, or sequence the exercises that address your pattern.

Our assessment uses posture photos and functional tests to identify the specific misalignments and muscle imbalances involved — which muscles are not doing their job, and which are working overtime to cover for them.

Our functional perspective

Root cause analysis: beyond imaging

Instead of asking “what’s wrong with your spine?” we ask “how is your body compensating, and why?” Looking at posture photos, we are looking for patterns — how the body has adapted to muscles that are not doing their job, how the skeleton has shifted to compensate, and how those adaptations create the stress that shows up as pain.

For example, we might see the upper body offset to one side, creating uneven loading on the lower back. A traditional assessment might attribute the pain to a bulging disc on that side. Our view is that the disc bulge is often a consequence of chronic uneven loading rather than the primary cause.

Muscle dysfunction and compensation

Most chronic back pain we see stems from muscle dysfunction and compensatory patterns. When muscles are not performing their role, the body compensates by overusing others to get the movement done.

Those compensating muscles work overtime and become tight and painful. Importantly, the muscles that hurt are usually not the source of the problem — they are the symptom. Rather than treating the painful area, we identify the dysfunctional muscle that created the need for compensation. As it starts working correctly, the compensating muscles can relax.

Personalized rather than protocol-based

Everyone receives a program built around their own postural analysis and functional testing, rather than a standard “back pain exercise protocol”. The exercises are simple, need no special equipment, and are done at home. Done consistently, they realign the body through muscle re-patterning.

The problems we’re trying to solve

At Activ8 Posture we try to address the issues Ramin exposes directly. We do not treat surgery as a first resort — many clients achieve meaningful relief through posture therapy instead. We aim past symptom management at the underlying pattern.

We are transparent about assessment findings and realistic about expectations. We spend real time explaining muscle dysfunction and compensation, showing people how their specific postural imbalances relate to their pain, because that turns treatment from something mysterious into something you can participate in.

And we give people home exercise programs that build independence rather than dependency. We are not trying to create clients who need us indefinitely.

When traditional medicine has its place

While we share Ramin’s concern about over-treatment, some symptoms need immediate medical attention. Red flags such as progressive neurological symptoms, loss of bowel or bladder control, or severe pain with fever can indicate serious pathology and warrant prompt medical assessment.

The best back pain care usually involves collaboration. Medical providers excel at diagnosing and managing serious pathology; functional practitioners address the mechanical and postural factors behind most chronic pain.

Ramin criticises over-reliance on imaging, and we would add a nuance: imaging has genuine uses in identifying serious pathology. What we question is using incidental imaging findings to drive treatment decisions for mechanical back pain, given that many structural abnormalities are present in people with no pain at all.

Our verdict on Crooked

Crooked is worth reading for anyone dealing with chronic back pain or weighing up surgery. It validates the experience of people who have sensed something is wrong with how back pain gets treated. It is strongest on the financial incentives behind over-treatment, the limited effectiveness of common interventions, and the case for active, patient-centred approaches.

Its limitation is the one any book has: it can tell you exercise works better than surgery, but it cannot give you the assessment and individual programming that effective treatment needs. Read it for the diagnosis of the system, then get assessed for the specifics of your own body.

Your next steps

If Ramin’s investigation resonates, start by asking harder questions before accepting any recommendation: what evidence supports it, what alternatives should be tried first, and what are the realistic success rates and complications?

Seek a functional assessment rather than accepting a diagnosis based on imaging alone. Postural analysis and functional testing can reveal contributors that imaging misses. And prioritise active over passive treatment — approaches that teach you something you can keep doing tend to outlast those done to you.

Ready to find out what’s driving your back pain?

Schedule your free 30-minute consultation and posture assessment — no cost, nothing to decide on the call, and an honest answer about whether we can help.

Frequently Asked Questions

Is back surgery really unnecessary?

For many people, often yes. As Ramin documents, the US performs far more back surgeries than other nations without better outcomes, and for most common conditions conservative approaches such as targeted exercise produce results equal to or better than surgery without the risks. Some conditions genuinely do require surgery. The point is exhausting conservative options first, and having that conversation with your surgeon rather than instead of them.

What does Cathryn Ramin recommend for back pain?

Ramin recommends finding what she calls a “back whisperer” who prioritises movement and exercise-based therapies over passive treatment or surgery. She points to approaches such as physical therapy and Pilates that actively engage people in their own recovery, and urges readers to evaluate recommendations critically — asking about evidence and alternatives, and being cautious about surgery.

Why do back pain treatments fail?

Often because they address symptoms rather than root causes. Traditional approaches focus on structural findings that may be incidental rather than causative, while overlooking the functional and postural factors driving the pain. Treatments also fail when they create dependency rather than capability. At Activ8 Posture we look for the actual root causes: dysfunctional muscles, compensatory patterns, and the postural imbalances creating chronic stress.

Can posture therapy help chronic back pain?

Where the pain stems from muscle imbalance and postural dysfunction, posture therapy can help, and that is consistent with Ramin’s finding that movement-based approaches outperform passive ones. The Activ8 Posture approach starts with a full postural assessment, then builds a program around what it finds. Many clients come to us after other treatments have not worked. Results vary between people, and the consultation is where we tell you honestly whether we think we can help.