Orthopedic Surgeons Order Most Musculoskeletal Extremity Imaging

May 2, 2018

Referral patterns for MSK imaging varied considerably by provider specialty.

Referral patterns for musculoskeletal (MSK) extremity imaging examinations to radiologists vary considerably by provider specialty, according to a study published in the American Journal of Roentgenology.

Researchers from Emory University School of Medicine in Atlanta, Georgia, and New York University Langone Medical Center in New York, sought to
to identify the specialty characteristics of providers referring MSK extremity imaging examinations to radiologists. The researchers obtained data from the 2014 Medicare Referring Provider Utilization for Procedures public use file to find data on provider referral for the imaging.

The results showed 4,275,647 MSK extremity imaging examinations were ordered and the most common specialties of the referring providers was orthopedic surgery:

Percentage of images per specialty

  • Orthopedic surgery 37.6%
  • Internal medicine 20.2%
  • Family practice 14.8%
  • Emergency medicine 7.9%
  • Rheumatology  5.7%


Orthopedic surgeons also more frequently ordered other imaging:

Orthopedic surgeons/All other specialties

  • MSK extremity CT 33,465 examinations < 2,000 examinations
  • MRI 325,485 examinations < 20,000 examinations
  • Radiography  1,249,748 examinations < 850,000 examinations


Physicians practicing internal medicine were the least likely to order MSK extremity ultrasound examinations (8,052 ordered examinations; for all other specialties, < 6,000 examinations).

After orthopedic surgeons, among the specialties most relevant to MSK imaging, the most frequent referrers were rheumatologists, for radiography (236,057 examinations) and ultrasound (2,034 examinations), and podiatrists, for CT (1,201 examinations) and MRI (19,159 examinations).

The most commonly ordered individual MSK extremity imaging services were:
• Knee radiography: 190,354 examinations ordered by orthopedic surgeons
• Hand radiography: 66,167 examinations ordered by rheumatologists
• Foot radiography: 137,042 examinations ordered by podiatrists
• Shoulder radiography: 11,299 examinations ordered by sports medicine specialists;
• Hip radiography: 9,838 examinations ordered by physiatrists


The researchers concluded that referral patterns for MSK imaging varied considerably by provider specialty. “Referral pattern insights may guide targeted efforts by radiologists to ensure the appropriateness of such examinations,” they wrote.