Referring a patient to an orthopaedic surgeon for an non-emergent condition, without a letter from an experienced physiotherapist is like applying for a job without references.

Terry Kane, PT


It’s estimated that over eighty percent of family physician referrals to orthopaedic surgeons are considered premature or inappropriate – these patients are either never seen by a surgeon or not offered surgery.

Although MRIs are very sensitive in identifying anatomical abnormalities, radiologists are the first to acknowledge that MRIs alone lack the specificity to determine if a surgical consult is required.

For this reason, an abnormal MRI without a clinical correlation from an experienced clinician is NOT a clinical indication for a surgical consult in non-emergent MSK conditions.

On the other hand, a joint study conducted by the Departments of Orthopaedics and Physical Therapy at the University of British Columbia (abstract)  found that experienced physiotherapists were 4x better at correctly identifying patients who required surgery than family physicians or emergency physicians (Physiotherapists = 91%; Physicians = 22%).


No one gets better sitting on a waiting list they shouldn’t be on.

In my opinion, the research supports that referring patients to an experienced orthopaedic physiotherapist for a triage assessment should be the first step in determining whether a surgical consult is indicated – not ordering an MRI.

Terry Kane PT





A physiotherapy triage service for orthopaedic surgery: an effective strategy for reducing wait times.


To investigate the effectiveness of a physiotherapy triage service for orthopaedic surgery referrals from primary-care physicians.


A prospective, observational design was used with patients referred to an orthopaedic surgeon based out of two small urban centres in British Columbia. The level of agreement between the physiotherapist and surgeon was determined using a weighted kappa statistic (κw) with 95% CI. A patient satisfaction questionnaire was administered, and the surgical conversion rate (SCR) was calculated to assess the level of appropriate referrals.


The analysis found substantial agreement (κw=0.77; 95% CI, 0.60-0.94) between surgeon and physiotherapist for surgical management decisions. All patients reported being “satisfied” or “very satisfied” with the overall care they received from the physiotherapist. The SCR of patients referred by the physiotherapist to the surgeon was 91%, versus 22% among patients referred by a general practitioner or emergency physician.


More than three-fourths of patients referred by primary-care physicians did not need to see a surgeon and were able to be managed by an experienced orthopaedic physiotherapist. This triage model could have considerable impact on orthopaedic wait times in Canada by minimizing unnecessary referrals; the model could also promote timely and conservative management of non-surgical conditions by physiotherapists.


gatekeeping; orthopaedics; practice guidelines as topic; waiting lists



[PubMed] PMCID:

PMC3817883 [Available on 2014/9/1]