Musculoskeletal Specialists Research Articles

Evaluation of Common Musculoskeletal Injuries in the Urgent Setting.

Musculoskeletal (MSK) complaints comprise approximately 20% of primary care and emergency department visits annually in the United States. At the same time, there is a shortage of MSK specialists specifically trained to evaluate and treat these conditions. Improper management of patients with MSK diagnoses increases morbidity and undesirable outcomes for patients and leads to higher health care costs resulting from extraneous tests and imaging. This resource consists of a set of four modules reviewing ankle, hip, shoulder, and wrist injuries and their initial treatment. Each module is a PowerPoint presentation formulated as a self-study guide for the evaluation of common MSK injuries by primary care and emergency medicine providers (initial providers). Each module includes material on physical examination, imaging, and management, including reduction and splinting, as well as indications for referral to an orthopedic specialist. The efficacy of the course for 43 first-year residents in internal medicine, orthopedic surgery, and the emergency department was measured using an external instrument. Pre- and posttest scores improved by 28% for knowledge of the material and by 30% for confidence level with the disposition of these injuries. All participants stated they were moderately to extremely satisfied with the course. Completion of this course will result in improved evaluation and management of injuries by initial providers, including-where appropriate-improved communication between these providers and treating surgeons.

Chronic Musculoskeletal Disabilities following Snake Envenoming in Sri Lanka: A Population-Based Study.

BackgroundSnakebite is a major public health problem in agricultural communities in the tropics leading to acute local and systemic impairments with resultant disabilities. Snakebite related long-term musculoskeletal disabilities have been a neglected area of research. We conducted a population-based, cross-sectional study in an agricultural community to describe the chronic musculoskeletal disabilities of snake envenoming.Methodology/Principal FindingsA sample representative of residents of a single district in a region of high incidence of snake envenoming was recruited to identify ever snakebite victims. They were evaluated for chronic musculoskeletal disabilities that had developed immediately or within four weeks after the snakebite and persisted over three months. In-depth interviews, validated musculoskeletal functional assessment criteria and specialists’ examinations were utilised. Among the 816 victims, 26 (3.2%, 95% confidence interval: 2.2–4.6%) had musculoskeletal disabilities, persisting on average for 13.4 years (SD = 14.4). The disabilities were mostly in lower limbs (61.5%) and ranged from swelling (34.6%), muscle wasting (46.1%), reduced motion (61.5%), reduced muscle power (50%), impaired balance (26.9%), chronic non-healing ulcers (3.85%), abnormal gait (3.85%), fixed deformities (19.2%) to amputations (15.4%). Based on disability patterns, six snakebite-related musculoskeletal syndromes were recognised. The offending snakes causing disabilities were cobra (30.8%), Russell’s viper (26.9%) and hump-nosed viper (7.7%). Cobra bites manifested muscle wasting (87.5%), reduced muscle power (87.5%), joint stiffness (62.5%) and deformities (37.5%) while viper bites manifested impaired balance (42.8%), pain (71.4%) and swelling (71.4%).Conclusions/SignificanceSnakebite envenoming is associated with considerable long-term musculoskeletal disabilities. Facilities for specialized care and rehabilitation need to be established in high risk areas.

Assessing musculoskeletal examination skills and diagnostic reasoning of 4th year medical students using a novel objective structured clinical exam.

BackgroundMedical students have difficulty performing and interpreting musculoskeletal physical examinations and interpreting the findings. Research has focused on students' knowledge deficits, but there are few direct assessments of students' ability to perform a hypothesis-driven physical examination (HDPE). We developed a novel musculoskeletal Objective Structured Clinical Exam (OSCE) focusing on HDPE skills for disorders of the shoulder, back and knee, and used it to explore medical student diagnostic reasoning.MethodsA multidisciplinary group of musculoskeletal specialists developed and gathered validity evidence for a three station OSCE focusing on the HDPE of the shoulder, back and knee, emphasizing the ability to anticipate (identify pre-encounter) expected physical exam findings, and subsequently perform discriminatory physical examination maneuvers. The OSCE was administered to 45 final year medical students. Trained faculty observed and scored students’ ability to anticipate exam findings and perform diagnostic examination maneuvers on simulated patients. Encounters were digitally recorded and scored again by another trained faculty member. Inter-rater reliability for each maneuver was estimated using type-2 intra-class correlations (ICC). Percentages of perfect scores for anticipation and performance were calculated. Pearson’s correlation between anticipation and performance scores was computed for each maneuver and their relationship to diagnostic accuracy was tested with logistic regression.ResultsInter-rater reliability was good (ICC between .69 and .87) for six exam maneuvers. Maneuver performance was overall poor, with no discriminatory maneuver performed correctly by more than two thirds of students, and one maneuver only performed correctly by 4 % of students. For the shoulder and knee stations, students were able to anticipate necessary discriminatory exam findings better than they could actually perform relevant exam maneuvers. The ability to anticipate a discriminatory finding correlated with the ability to perform the associated maneuver correctly, with the exception of the ability to perform maneuvers needed to diagnose a torn anterior cruciate ligament of the knee. Neither the ability to anticipate or perform was predictive of identifying correct diagnoses for the different cases.ConclusionsA novel musculoskeletal OSCE, based on principles of the hypothesis-driven physical examination, was able to identify significant deficiencies in examination skills needed to diagnose common disorders of the shoulder, back and knee amongst graduating medical students. In addition, the OSCE demonstrated that accurate anticipation of discriminatory examination findings correlates with ability to perform the associated maneuver; however, the ability to anticipate exceeds the ability to perform. Students do not appear to be using the physical exam to inform their diagnostic reasoning. The findings of this study have implications for both assessment and teaching of the musculoskeletal exam.Electronic supplementary materialThe online version of this article (doi:10.1186/s12909-016-0780-4) contains supplementary material, which is available to authorized users.

Evaluation of Wrist Injuries in the Urgent Setting

Musculoskeletal (MSK) complaints comprise approximately 20% of primary care and emergency department visits annually in the United States. More than two million emergency department visits in 2009 related to wrist injury and wrist disease. At the same time, there is a shortage of MSK specialists specifically trained to evaluate and treat these conditions. Improper management of patients with MSK diagnoses increases morbidity and undesirable outcomes for patients and leads to higher health care costs resulting from extraneous tests and imaging. This resource consists of a 50-slide PowerPoint presentation formulated as a self-study guide for the evaluation of wrist injuries and disease by primary care providers (PCPs). It includes material on physical examination, anatomic considerations, imaging, and management, including reduction and splinting, as well as referral. The efficacy of the course for 30 first-year residents in internal medicine, orthopedic surgery, and the emergency department was measured using an external instrument. Pre- and posttest scores improved by 25% for knowledge of the material and by 30% for confidence level with the disposition of these injuries. All participants stated they were moderately to extremely satisfied with the course. Completion of this course will result in improved evaluation and management of wrist injuries and disease by PCPs, including—where appropriate—improved communication between PCPs and treating surgeons. Please see the end of the Educational Summary Report for author-supplied information and links to peer-reviewed digital content associated with this publication.

Lactation Consultants’ Perceptions of Musculoskeletal Disorders Affecting Breastfeeding

Objective: The study aimed to investigate IBCLCs’ demographic profile, perceptions of breastfeeding musculoskeletal disorders in infants, and referral patterns.Method: IBCLCs from Canada and the United States (N = 13,017) were invited to participate in an online survey questionnaire emailed by the International Board of Lactation Consultant Examiners.Results: Response rate was 18.9% (N = 2,457). Most IBCLCs had a nursing background (64.8%) and practiced in a hospital setting (57%). Most reported referral of infants for musculoskeletal treatment (73.9%). The first professional referral was made to a pediatrician (47%), followed by craniosacral therapist (16%), and chiropractor (14%). Professional expertise was the chief reason for referral (43%). The most common latch issues referred for were tongue-tie (27%), painful latch (24%), neck problems (18%), and nonlatching (9%). Congenital torticollis (25%) and neck tension (14%) were the main musculoskeletal problems recognized by IBCLCs. Approximately half the respondents (51%) were comfortable recognizing musculoskeletal issues in babies. Most respondents (91%) noticed breastfeeding improvement following manual treatment.Conclusion: IBCLCs refer to musculoskeletal specialists promptly following the first visit. More collaboration between professions may help foster the wide interprofessional support needed to improve breastfeeding rates.

Chest Low-Dose Computed Tomography for Early Lung Cancer Diagnosis as an Opportunity to Diagnose Vertebral Fractures in HIV-Infected Smokers, an ANRS EP48 HIV CHEST Substudy.

To estimate the prevalence of vertebral fractures on chest low-dose computed tomography (LDCT) in HIV-infected smokers. Cross-sectional study of vertebral fractures visualized on chest LDCT from a multicenter prospective cohort evaluating feasibility of chest LDCT for early lung cancer diagnosis in HIV-infected subjects. Subjects were included if 40 years or older, had been active smokers within the last 3 years of at least 20 pack-years, and had a CD4 T-lymphocyte nadir cell count <350 per microliter and an actual CD4 T-cell count >100 cells per microliter. Spinal reconstructed sagittal planes obtained from chest axial native acquisitions were blindly read by a musculoskeletal imaging specialist. Assessment of the fractured vertebra used Genant semiquantitative method. The study end point was the prevalence of at least 1 vertebral fracture. Three hundred ninety-seven subjects were included. Median age was 49.5 years, median smoking history was 30 pack-years, median last CD4 count was 584 cells per microliter, and median CD4 nadir count was 168 cells per microliter; 90% of subjects had a viral load below 50 copies per milliliter. At least 1 fracture was visible in 46 (11.6%) subjects. In multivariate analysis, smoking ≥40 packs-years [OR = 2.5; 95% CI: (1.2 to 5.0)] was associated with an increased risk of vertebral fracture, while HIV viral load <200 copies per milliliter [OR = 0.3; 95% CI: (0.1 to 0.9)] was protective. Prevalence of vertebral fractures on chest LDCT was 11.6% in this high-risk population. Smoking cessation and early introduction of antiretroviral therapy for prevention of vertebral fractures could be beneficial. Chest LDCT is an opportunity to diagnose vertebral fractures.

Transcuneiform Crush Injury: A Case Report

Introduction: Transcuneiform fracture patterns without dislocations are uncommon. In a review of the literature, numerous case reports describe cuneiform fracture-dislocations involving either the transmetatarsal or midtarsal joint complexes due to direct trauma; however, an isolated transcuneiform fracture pattern without dislocation has not been reported. Methods: We present a rare injury of the foot: an isolated transcuneiform fracture without associated dislocation of the tarsometatarsal joint or midtarsal joint complex. Case: A 29 year old active duty Army male sustained direct blunt trauma to his foot when a 20 ton trailer fell onto it. His initial presentation prompted protected weight bearing after a clinical exam revealed soft tissue injury and tenderness to palpation about the dorsum of his midfoot. Due to persistent symptoms, he was referred to a musculoskeletal specialist. Radiographs and computed tomography (CT) images demonstrated a minimally displaced comminuted transcuneiform fracture involving the medial and intermediate cuneiforms without evidence of dislocation or subluxation. Treatment consisted of non-weight bearing cast immobilization with crutches for ten weeks before being transitioned into a weight bearing control ankle motion (CAM) boot. Radiographic evidence of healing was documented at 4 weeks by callus formation at the first metatarsal and medial cuneiform. The patient returned to low impact activity by 10 month follow-up without surgical intervention. Discussion and Conclusions: Blunt trauma to the midfoot can result in isolated or complex fracture patterns without the typical fracture-dislocation following high mechanism trauma. Appropriate clinical suspicion and careful physical examination can facilitate timely diagnosis and treatment. Minimally displaced transcuneifom fracture patterns without associated midfoot dislocation injuries can be treated nonoperatively with protected weight bearing, close radiographic and clinical follow up, and gradual advancement to activity with acceptable clinical outcomes.

Optimal management of hemophilic arthropathy and hematomas.

Hemophilia is a hematological disorder characterized by a partial or complete deficiency of clotting factor VIII or IX. Its bleeding complications primarily affect the musculoskeletal system. Hemarthrosis is a major hemophilia-related complication, responsible for a particularly debilitating chronic arthropathy, in the long term. In addition to clotting factor concentrates, usually prescribed by the hematologist, managing acute hemarthrosis and chronic arthropathy requires a close collaboration between the orthopedic surgeon and physiotherapist. This collaboration, comprising a coagulation and musculoskeletal specialist, is key to effectively preventing hemarthrosis, managing acute joint bleeding episodes, assessing joint function, and actively treating chronic arthropathy. This paper reviews, from a practical point of view, the pathophysiology, clinical manifestations, and treatment of hemarthrosis and chronic hemophilia-induced arthropathy for hematologists, orthopedic surgeons, and physiotherapists.

Radiological features do not predict failure of two-stage arthroplasty for prosthetic joint infection: a retrospective case-control study.

BackgroundThe management of prosthetic joint infection is complex and there is a lack of standardisation of approaches. We evaluated the role of plain film radiography in predicting prosthesis failure after the first stage of a two-stage revision procedure in a retrospective case–control study.MethodsPlain films for 41 patients aged 46 to 87 years (mean 69) were assessed by two musculoskeletal specialist radiologists for seven features (retained or new metalwork, retained cement or restrictor, new fracture, local antimicrobial delivery system and drain) we hypothesised may predict for failure. Inter-observer agreement was assessed by Kappa score and logistic regression analysis was performed to evaluate the relationship of the seven radiological features adjusting for patient age, gender and number of previous revisions.ResultsThere was substantial inter-observer agreement, with a Kappa score of 0.73 (95% CI 0.72-0.74) for all data points collected. Concordance was 100% for evaluating the presence or absence of an antimicrobial delivery system or drain, with lower consensus for evaluating cement (Kappa 0.60, 95% CI 0.35-0.84) and fractures (Kappa 0.59, 95% CI 0.31-0.87). None of the variables’ conditions significantly predicted failure.ConclusionsOur findings support the opinion that surgical expertise which maximizes removal of foreign material is sufficient in conjunction with antibiotic therapy.Electronic supplementary materialThe online version of this article (doi:10.1186/1471-2474-15-300) contains supplementary material, which is available to authorized users.

Teaching clinical anatomy of the knee using a 3‐column methodology approach (536.6)

INTRODUCTION. The knee is a weight bearing synovial joint, which is frequently injured. May lead to significant time off work and loss of fitness activity resulting in a sedentary lifestyle. Contemporary methodology of knee anatomy teaching applies a systems approach (SA). SA to the knee does not intuitively integrate the mechanism of injury (MoI), symptoms and examination with common pathologies. Musculoskeletal training during family practice residency is approximately 10% of the curriculum. Objective of this study was to apply a 3‐column approach of teaching knee anatomy. METHODS. Knee was divided into 3 columns and taught as a tutorial to first year medical students during lab versus a systems lecture approach. Likert scale and random interviews were conducted. RESULTS. A 3‐column approach was successfully taught and well received regarding Likert scores and interview analysis. DISCUSSION. SA to knee anatomy teaching often leaves a void between classroom and clinic. Musculoskeletal specialists focus on the posteromedial and posterolateral regions of the knee. This pilot work successfully applied a 3‐column approach integrating structures, MoI, examination and symptoms with common pathologies. CONCLUSSION. This study suggests a 3‐column teaching approach may provide a successful platform enabling students to apply knee anatomy in the clinical arena resulting in critical thinking aiding diagnosis.

Evaluation of the usage and influence of groin ultrasound in primary and secondary healthcare settings

Groin ultrasound scan (USS) is used to aid the diagnosis of inguinal hernias. Our radiology department offers access to image symptomatic patients for general practitioners (GPs) as well as surgeons. We examined the utilisation of groin USS in primary and secondary healthcare settings, and investigated its influence on proceeding to surgery. A retrospective data analysis was performed for patients seen in the surgical outpatient clinics (January 2010-January 2011). Clinical, radiological, and surgical findings were compared. 267 USS were performed by musculoskeletal radiology specialists; patients were referred for USS by GPs in 98 cases (36.7 %), compared to 169 cases (63.3 %) where the referral for USS was organised by surgeons. Clinical examination by surgeons detected inguinal hernias in 105 groins (39.3 %), and USS detected inguinal hernias in 154 groins (57.7 %). Of 162/267 (60.7 %) cases where clinical examination was negative, 98/162 (60.4 %) also had a negative USS; only five of these patients (5.1 %) underwent surgery. In the 64/162 (39.6 %) cases where only the USS findings were positive, 19/64 underwent surgery (29.7 %). When hernia was detected on both USS and clinical examination (n = 90), 68/90 underwent surgery (75.6 %). For patients who underwent surgery, sensitivity for hernia detection was 80 % for clinical examination versus 96.3 % for USS. Groin USS is highly sensitive, and patients could be referred for USS by GPs when clinical examination findings are equivocal or negative. If USS is also negative, patients may be managed conservatively in primary care setting if they remain asymptomatic. Positive clinical examination findings appear to have a greater influence in the decision to treat surgically.

A conceptual model of musculoskeletal disorders for occupational health practitioners

A conceptual model of musculoskeletal disorders for occupational health practitioners

Evaluation and treatment of extremity metastatic disease.

Metastases can occur as part of the natural progression of a variety of malignancies and their mode of spread, manner of presentation, and prognosis are as variable as their primary sources. The ultimate goal of musculoskeletal treatment of skeletal metastases is to get the patient in question back to his or her previous level of function as soon as possible. Skeletal metastases are seldom life threatening and their treatment will rarely render someone cured of their primary disease. Nevertheless, involvement of a musculoskeletal specialist as a part of the multidisciplinary approach can and very often does provide significant improvement in patients' qualities of life. The purpose of this chapter is to discuss the evaluation of a patient with suspected metastatic disease involving the musculoskeletal system and their pre-, intra-, and post surgical management as part of a multidisciplinary team.

Agreement Among Musculoskeletal Pediatric Specialists in the Assessment of Radiographic Joint Damage in Juvenile Idiopathic Arthritis

To evaluate agreement among musculoskeletal pediatric specialists in assessing radiographic joint damage in juvenile idiopathic arthritis (JIA). Two pediatric rheumatologists, 2 pediatric radiologists, and 2 pediatric orthopedic surgeons evaluated independently 60 radiographs of both wrists and hands of children with polyarticular-course JIA. Films were scored using an adapted and simplified version of the Larsen score, ranging from 0-5. Study radiographs were selected from 568 films used in a previous study aimed to validate an adapted pediatric version of the Sharp/van der Heijde (SHS) score. To enable comparison of specialists' scores with the adapted SHS score, the 60 radiographs were divided into 6 classes of severity of damage based on quintiles of the adapted SHS score. Agreement was evaluated in terms of absolute agreement and through weighted kappa statistics. The pediatric radiologists tended to assign lower scores and to provide more frequently scores of 0 than did the other specialists. Weighted kappa for the 3 pairs of specialists ranged from 0.67-0.69, indicating substantial agreement. Absolute agreement ranged from 51.3-55.7%, depending on the pair of specialists examined. Both absolute and weighted kappa concordance between specialists' scores and the adapted SHS score were poorer for the pediatric radiologist than for the other specialists. We observed fair agreement in the assessment of radiographic damage among pediatric specialists involved in the care of children with JIA. The radiologists tended to be more reserved than the rheumatologists and orthopedic surgeons in labeling radiographs as damaged or in considering changes as important.

Chinese Hemophilia Joint Health Score 2.1 reliability study

To meet the rapidly expanding need for musculoskeletal (MSK) specialists [physiotherapists (PTs), physiatrists] in haemophilia care in China, a 4-day Train the Trainer workshop was conducted in July/August 2009 in Beijing. A key focus was to train the participants to administer the Hemophilia Joint Health Score (HJHS) version 2.1 for effectively evaluating the MSK health of boys <18years of age with haemophilia. The aim of this study was to test the HJHS version 2.1 inter- and intra-rater reliability in a group of Chinese PTs and physiatrists with limited experience in haemophilia care. Each of the trained Chinese physiatrists and PTs examined eight boys 4-17years old with moderate and severe haemophilia on day 1 and repeated the examination on the same patients the next day using the HJHS version 2.1. The boys had a wide range of target joint involvement and arthropathy. The HJHS score sheet, work sheets and manual had been translated into simple Chinese prior to the study. The interrater (ICC 0.90) and intra-rater (ICC 0.91) reliability was excellent. The internal consistency of the HJHS items was also excellent with Cronbach's alpha of 0.86. With basic training in the administration of the HJHS version 2.1, the tool was reliably administered by Chinese PTs and physiatrists with limited haemophilic experience.

PReS-FINAL-2164: Agreement among musculoskeletal pediatric specialists in the assessment of radiographic joint damage in juvenile idiopathic arthritis

The management of children juvenile idiopathic arthritis (JIA) is ideally conducted through the establishment of a multidisciplinary team of musculoskeletal pediatric specialists. Some therapeutic decisions, either medical or surgical, are made through discussion and consensus between specialists by viewing patient radiographs. However, it is unknown whether and to what extent different specialists agree in the assessment of the amount of radiographic joint damage.

Can Musculoskeletal Specialists Serve as Sentinels for Domestic Violence?

Can Musculoskeletal Specialists Serve as Sentinels for Domestic Violence?

The Effect of JPEG2000 Compression on Detection of Skull Fractures

To investigate the effect of the Joint Photographic Experts Group (JPEG2000) 30:1 and 60:1 lossy compression on the detection of cranial vault fractures when compared to JPEG2000 lossless compression. Fifty cranial computed tomography (CT) images were processed with three different level of JPEG2000 compression (lossless, 30:1 lossy, and 60:1 lossy) creating three sets of images. These were presented to five musculoskeletal specialists and five neuroradiologists. Each reader read at two of the three compression levels. Twenty-two cases contained a single fracture; the remaining 28 cases contained no fractures. Observers were asked to identify the presence or absence of a fracture, to locate its site, and rate their degree of confidence. Receiver operating characteristic (ROC), jackknife free-response receiver operating characteristic (JAFROC) and the Dorfman-Berbaum-Metz multiple reader multiple case (DBM-MRMC) analyses were used to explore differences between the lossless and lossy compressed images. JPEG2000 lossless and 30:1 lossy compression demonstrated no significant difference in their performance with JAFROC and DBM-MRMC analysis (P < .416); however, JPEG2000 30:1 lossy compression demonstrated significantly better performance than 60:1 lossy compression (P < .016). A significant increase in misplaced confidence ratings was also seen with 60:1 (P < .037) over 30:1 lossy and lossless compression. JPEG2000 60:1 compression degrades the detection of skull fractures significantly while increasing the confidence with which readers rate fractures compared with 30:1 lossy and lossless compression. JPEG2000 30:1 lossy compression does not significantly change performance when compared to JPEG2000 lossless for the detection of skull fractures on CT.

Study to EstablishOjeok-san(Five Accumulation Powder:Wu Ji San) Administration Criteria and a Questionnaire to Evaluate the Holistic Effects ofOjeok-sanon Patients with Low Back Pain

The study objectives were to establish ojeok-san (Five Accumulation Powder: wu ji san) administration criteria and a questionnaire to evaluate the holistic effects of ojeok-san on patients with low back pain (LBP). Texts and literatures, recommended by specialists, were searched to gather ojeok-san-related symptoms. Then, the opinions of Oriental medicine doctors (OMDs) practicing in Seoul were surveyed to ask which symptoms they consider the most in clinical practice. Based on the survey, selection of potential items for the questionnaire was made. The final version was established based on the results of the survey and Delphi process of musculoskeletal diseases specialists. In order to evaluate the reliability and validity of the newly developed assessment tool (Ojeok-san Low Back Questionnaire: OLQ), patients with chronic LBP were recruited. OLQ and other tools such as visual analogue scale, numeric rating scale, Roland-Morris Disability Questionnaire, Modified-Modified Schober test, and 36-Item Short Form Health Survey were applied to the subjects in a 2-week interval. Test-retest reliability, internal consistency, and convergent and discrimination validity were assessed. A total of 90 potential items were generated by the research team. One hundred and two (102) OMDs fully replied to the survey. Based on the survey results, 34 items were initially selected as potential items. Through Delphi method of experts, 10 top items, rated more than 5 points on a scale of 10, were finally established. The 10 items were each established as a response scale of 0-10 (0 as no symptom and 10 as the most excessive form of symptom). Based on the above stages, an initial OLQ was established and used in the evaluation phase. The validity and reliability of OLQ assessment results showed high test-retest reliability, intraclass correlation coefficient, and internal consistency. The newly developed Ojeok-san administration criteria and questionnaire may be a promising tool for future Oriental medicine clinical study protocols.

Access to Musculoskeletal Specialists and Resources in Free and Charitable Clinics: A Survey of Clinic Directors

To evaluate the capabilities and resources of free and charitable clinics in the United States to deliver musculoskeletal care to an indigent population. A voluntary, anonymous, cross-sectional survey. Electronic mailing list for the National Association of Free and Charitable Clinics in September 2011, and in person at the Annual Summit for the National Association of Free and Charitable Clinics in October 2011. At the time of survey, 427 member-clinics were eligible for participation. One hundred forty-five (34%) respondents were included in data analysis. None. Answers to a questionnaire regarding access to musculoskeletal care. The average annual clinic volume was 5690 patient visits. Low back pain was the most common orthopedic complaint. Access to musculoskeletal specialty consultants was rated as poor or worse in 83% of clinics surveyed. The majority of respondents (63%) believed that their staff was able to treat only half or fewer of the patients who presented with musculoskeletal complaints in their clinic. The resource most needed to treat these conditions was musculoskeletal physician consultants. Indigent populations have a strong need for musculoskeletal care, but affordable access to physiatrists and other musculoskeletal specialists is extremely limited. Personnel at surveyed clinics believed that the greatest need to improve care is better access to these specialty physicians.