Sword Health and Hinge Health Are Fighting the Wrong Battle

In the past week, the CEOs of Hinge Health and Sword Health, two of the biggest players in digital musculoskeletal care, have been publicly trading jabs on LinkedIn. You can catch up on the back-and-forth here: Hinge CEO Daniel Perez’s post.

I believe there’s real value in debating clinical models. If we didn’t have open discussion, we wouldn’t have made progress around direct access laws. Dialogue is how the industry moves forward.

Beneath the surface of the public back-and-forth are important questions: Who should lead MSK care? How should technology be used? What does real accountability look like?

As currently the top-cited researcher in direct access MSK care, a Doctor of Physical Therapy who has actually worked with patients, the founder of the first research lab focused on direct access, and now the CEO of an MSK company, I bring a perspective shaped by both hands-on clinical experience and business realities.

Point One: Who Should Guide MSK Care? 

One of the central questions in the current debate is the role of physical therapists versus health coaches. Virgílio Bento, CEO of Sword Health, has criticized Hinge Health for using what he calls “non-clinical” specialists. In a recent LinkedIn post, Sword even referenced med school, suggesting that only physicians are qualified to lead musculoskeletal care.

It’s an odd argument. Physical therapists don’t go to med school, and they aren’t trying to. That’s by design.

Today’s physical therapists hold doctorate degrees and are trained specifically in musculoskeletal care. They use active treatments to help patients avoid unnecessary imaging, medications, injections, and surgery. Physicians, by contrast, are more likely to use passive interventions such as drugs, injections, or surgical referrals. Conservative care is widely recognized as the best first step. 

Further, Doctors of Physical Therapy are non-surgical specialists, as opposed to surgeons who know more about surgical care than the modern evidence (root cause diagnostics, neurophysiological pain education, etc.) guiding non-surgical care. When >90% of wear and tear MSK cases are non-surgical, it makes sense to see a non-surgical specialist as the first line of care.

As a trained Doctor of Physical Therapy, I believe the quality of the physical therapy is one of the most important parts of any MSK company. That’s why I look for the top 5 percent of PTs in the country, using the Orthopedic Clinical Specialist (OCS) certification as my benchmark. It reflects advanced clinical reasoning and a real commitment to evidence-based care, which is exactly what members of health plans deserve.

I also believe people deserve compassionate care. Real, human connection can’t be replicated by a screen alone. There’s something powerful that happens when you're talking to someone who is truly listening, explaining what’s going on in your body, and helping you feel confident in your path forward. That kind of interaction can change the trajectory of someone’s recovery.

“I worked with my provider for a few months and once my treatment ended, I had mixed feelings because while I knew I was well enough to exit the program, I also recognized I was going to miss getting the type of care and attention I received from Aware Health. Since then, I’ve had another issue pop up and was quick to schedule another meeting to get it figured out. I’m looking forward to reconnecting with my provider again!” -End User

Coaches play an important role in the care model. Just as physicians aren’t trained in active, conservative treatments, physical therapists receive limited formal training in behavior change. Coaches help patients stay engaged, build healthier habits, and follow through on care plans in ways that PTs alone often can’t.

Bento’s point that coaches shouldn’t be doing the job of a physical therapist is one I agree with. But that doesn’t mean coaches don’t belong in the model. When deployed thoughtfully, they help patients succeed.

Physicians also play an important role in the care model, especially when conservative care isn’t enough. Along with Doctors of PT in some states, they can order and interpret imaging when it meaningfully impacts the treatment plan. And in some cases, surgery is necessary. The key is knowing when to escalate care and making sure it happens with the right clinical judgment at the right time. 

Which leads me to my second point:

Point Two: The Role of Technology in MSK Care

Technology should be a tool that empowers the provider and the diagnosis. It should never try to replace them. That is where I see a fundamental difference in approach between Sword, Hinge, and what we’re building.

Both Sword Health and Hinge Health rely heavily on algorithms to drive care. The result is often a standardized, one-size-fits-all treatment path. Everyone gets grouped into the same flow, and we lose the clinical precision needed to treat the person, not just the condition.

Here’s what those algorithms are not doing: Screening for painful conditions that could be caused by serious diagnoses like cancer, blood clots, or fractures. These conditions are rare, but they matter. Missing them delays the right care and puts patients at risk, sometimes costing them their life..

We are focused on building technology that scales the right kind of care at the right time. Our platform is designed to guide accurate diagnosis, streamline triage, and support customized care plans so that every patient receives just the right number of high-impact visits. It’s not about replacing providers. It’s about about building sophistication on the backend to help them work smarter and deliver better results, faster, on the frontend.

I didn’t learn this in theory. In the clinic, I saw firsthand how much the quality of diagnosis could vary depending on who a patient saw first. When you get the diagnosis right early, many patients improve in just one visit. But get it wrong, and that person ends up on the wrong path. More tests, more referrals, and more time in pain. I treated people who came in with what looked like routine back pain but turned out to be a spinal tumor. I saw swelling that wasn’t a knee injury but a blood clot. These moments stay with you. 

That’s also why I’m so passionate about building standardized clinical decision rules into our model. We use technology to make sure every patient is screened safely and consistently, no matter where they are or who they speak to first. It helps reduce risk, lower costs, and get people on the right path faster.

Point Three: Accountability to the Customer

So far, most of this article has focused on what’s best for the patient. But I would be remiss not to talk about outcomes from the employer’s perspective. Any MSK solution worth investing in has to do more than deliver a good experience. It has to control risk and drive meaningful savings for the plan.

Sword and Hinge are both focusing on engagement as though it’s the ultimate metric that proves value. You know why? Because that’s how they get paid. Their revenue is tied to how many people use the platform, not what happens after they do.

The musculoskeletal problem is massive. Up to half of all people will experience an MSK condition, and it’s one of the leading reasons employees miss work. If you’re going to invest in a condition that affects a large portion of your population, MSK is the place to start.

But that also means you can’t afford to cherry-pick who gets help. Avoiding the broader population because it’s expensive to engage each user doesn’t solve the problem. It just delays the cost.

If you're spending $1,000 per engaged member and only reaching a small fraction of your people, the math simply doesn’t work in your favor. 

When I worked in the clinic, I was told to bring patients in for more visits even when I knew they didn’t need them, because we got paid per visit. That is how the fee-for-service model works. And it is not all that different from how Sword and Hinge Health operate today. Their revenue depends on how many people engage, not how many images, surgeries are avoided or to what extent functional outcomes are improved. 

From my perspective, the model should align with what the customer actually cares about: Giving lots of people care and getting an ROI on that investment. We ask our customers to pay a little for every eligible member through a capitated approach, and offset the fixed investment with a performance guarantee tied to ROI. This way, the employer is motivated to drive engagement without worrying about rising costs.

Closing Thoughts 

I’m glad these conversations are happening. I wish they were unfolding in a more productive way.

I hope this article highlights a few of the areas where we see things differently. At Aware Health, we’re building a musculoskeletal care model that is clinically led, deeply human, and accountable to both functional and financial outcomes.

If you’re looking to invest in a solution that prioritizes people and guarantees results, I’d love to connect on LinkedIn or you can request a demo of our platform.