Strategic Guide for MD Graduates with Low Step Scores in Orthopedic Surgery

Understanding the Challenge: Low Step Scores in an Ortho World

Orthopedic surgery is one of the most competitive specialties in the allopathic medical school match. Programs receive far more applications than they can seriously review, and standardized metrics—Step scores, clerkship grades, research—become quick filters.

For an MD graduate, discovering you have a low Step 1 score (or generally below average board scores) can feel like the end of your orthopedic surgery residency plans. It is not. It does, however, change your strategy and the level of intentionality required.

In this article, we’ll focus on low Step score strategies specifically for MD graduates targeting orthopedic surgery residency, with a practical, action-oriented approach. We’ll assume:

• You already know ortho is what you want.
• Your Step 1 (and/or Step 2) is at or below the typical range for successful ortho applicants.
• You’re willing to work harder and smarter than average to offset those numbers.

We’ll cover how to:

• Realistically assess your competitiveness as an MD graduate residency applicant in ortho.
• Build a high-impact, score-compensating application.
• Optimize letters, research, and rotations for the ortho match.
• Decide when to consider backup plans without prematurely giving up.

---

1. Reframing Your Low Step Score: From Anchor to Data Point

Before you build a strategy, you need clarity on where you stand and what can be improved.

1.1 What Counts as a “Low” Score in Ortho?

While Step 1 is now pass/fail, past data and current PD surveys tell us that:

• Ortho applicants typically have strong test performance (especially on Step 2 CK).
• Program directors still rely heavily on Step 2 CK and NBME/COMAT ortho exams, plus internal exams during auditions.

For many ortho programs:

• Below-average board scores means:
  • Step 2 CK significantly below the national mean, or
  • Borderline pass on Step 1 (if you took it before P/F) or needing multiple attempts.
• Even one failed attempt can be a major filter at some programs.

Your low score could mean:

• A single exam below average.
• A failed attempt.
• A pattern of below average performance on multiple exams.

Each scenario requires a different narrative and strategy.

1.2 Honest Self-Assessment: Not Just Numbers

Before committing to an aggressive plan, ask:

1. Is ortho truly my #1 choice, even if it means extra years (research, prelim, transitional paths)?
2. Do I have strong non-score strengths?
   • Solid clinical performance
   • Strong hands-on/technical aptitude
   • Evidence of resilience and work ethic
   • Strong interpersonal skills, teamwork, leadership
3. Am I willing to geographically compromise (any state, any region, less “brand name” programs)?

If your honest answers are “yes,” then a low Step score is an obstacle, not a stop sign.

1.3 The Narrative Around a Low Step Score

Programs aren’t just looking for high numeric performance; they are also screening for:

• Reliability
• Resilience
• Ability to learn from mistakes

You will need a coherent explanation for your low score, framed around:

• A specific factor (e.g., poor preparation strategy, life event, anxiety not managed).
• Concrete steps you took to improve.
• Evidence of improvement (Step 2 CK, in-training exam scores, clinical performance).

Example framing in an ERAS personal statement or interview:

“My Step 1 results were disappointing and did not reflect my capabilities. I changed my study structure, sought academic coaching, and used structured question blocks with active review. The same approach helped me increase my Step 2 CK performance, and I’ve consistently scored above the mean on in-house exams and shelf exams since then.”

You’re not making excuses; you’re showing growth and ownership.

---

2. Academic Recovery: Turning Weakness into a Demonstrated Strength

Your primary academic task with matching with low scores is to prove:

1. You can perform at or above the level of successful residents.
2. Your poor exam performance is a past event, not an ongoing pattern.

2.1 Step 2 CK: Your Second Chance (And Sometimes Only Chance)

With Step 1 now pass/fail for many, Step 2 CK is often the key numeric filter.

If your Step 1 was low or borderline:

• Treat Step 2 CK as a must-win exam.
• A strong Step 2 CK (even just at or slightly above national mean) can:
  • Reassure programs you can handle clinical decision-making.
  • Partially offset a poor Step 1 result.

Practical strategies:

• Structured prep plan (10–12 weeks):
  • Daily question blocks (UWorld and/or AMBOSS) with timed conditions.
  • Weekly NBME practice exams to monitor progress.
  • Dedicated review of weak systems, especially MSK, trauma, and surgery.
• Consider:
  • School academic support services
  • Peer tutors
  • Formal Step prep courses if finances allow and self-study has previously failed

If Step 2 CK is already low:

• You lose this main lever, so you must double down on every other aspect of your application: clinical performance, away rotations, research, and networking.

2.2 Clerkship Honors and Sub-I Performance

For MD graduate residency applicants with low board scores, clerkship and sub-internship performance becomes critical:

• Aim for Honors in:
  • Surgery
  • Internal Medicine
  • Orthopedic electives
• On evaluations:
  • Ask attendings what they value most (initiative, note quality, OR prep).
  • Show up early, know your patients, and be over-prepared for cases.
• Ask directly at the end of rotations:
  • “Could you provide feedback on how I’m doing compared to other students?”
  • “Is there anything I can do in the remainder of the rotation to strengthen my performance for an orthopedic surgery residency application?”

Better evaluations = stronger letters = higher chance a program will look past scores.

2.3 In-Training or Other Standardized Tests

If you take orthopedic in-service or internal exams during a research year or preliminary surgery year, treat these like redemption opportunities:

• A strong in-training exam score during a prelim or transitional year is concrete evidence that your earlier low Step performance was not your ceiling.

---

3. Building a High-Impact Ortho Application with Low Scores

Once you accept the reality that you can’t change your Step numbers, your energy should shift fully to everything else you can control.

3.1 Strategic Research: Depth, Not Just Volume

In orthopedic surgery, research is a powerful way to:

• Show commitment to the specialty.
• Demonstrate academic curiosity and work ethic.
• Get to know faculty who can write strong letters or advocate for you.

If you have below average board scores, consider:

Research Year (Dedicated)

An optional, but often high-yield path for low-score MD grads:

• One full year (usually between 3rd and 4th year, or post-graduation).
• Ideal if:
  • Your Step scores are truly weak for ortho and you have little existing research.
  • You can join a productive ortho research group with good mentorship.

During a research year, aim to:

• Join multiple projects early (retrospective chart reviews, case series, outcomes studies).
• Be the “workhorse” student: data collection, IRB applications, manuscript drafts.
• Target:
  • Several abstracts/posters/presentations at regional or national meetings.
  • At least 1–2 manuscripts submitted to peer-reviewed journals.
• Attend conferences (AAOS, subspecialty meetings) to network with faculty and residents.

No Research Year, But Focused Productivity

If a full year isn’t feasible:

• Start with one or two faculty mentors at your home ortho department.
• Volunteer for small, quick-win projects:
  • Case reports
  • Retrospective analyses
  • Quality improvement
• Ask to help with:
  • Data cleaning
  • Chart review
  • Literature review
• Track your contributions; update your CV meticulously.

Programs want to see a trajectory—even a few well-executed projects can distinguish you from other low-score applicants.

3.2 Letters of Recommendation: Your Most Powerful Non-Numeric Asset

For an applicant with a low Step 1 score or low Step 2 CK, letters from orthopedic surgeons can dramatically influence whether programs even read the rest of your application.

Aim for:

• 3–4 strong letters, including:
  • At least 2 orthopedic surgeons who know you well.
  • Ideally, 1–2 from academic faculty in ortho who are known in the field.
  • Possibly 1 letter from:
    • General surgery clerkship director, or
    • Research mentor (especially if ortho faculty), or
    • Program director from a prelim year.

Key points to secure strong letters:

• Perform at your best on ortho rotations (home and away).
• Schedule a meeting near the end of the rotation:
  • Ask if they feel they know you well enough to write a strong letter.
  • Provide a CV, personal statement draft, and USMLE transcript.
• If your scores are low, you can say:
  • “My Step scores do not reflect my capabilities. I am working hard to demonstrate my strengths clinically and academically. A detailed letter highlighting my work ethic and clinical growth would be very meaningful for my application.”

A detailed, story-rich letter that says, “I would absolutely trust this person to be my resident,” often outweighs a few points difference on a test.

3.3 Personal Statement: Addressing, Not Obsessing over, Low Scores

Your personal statement should primarily answer:

• Why orthopedic surgery?
• Why you are suited to the specialty (skills, values, experiences)?
• What you bring to a program (work ethic, teamwork, resilience)?

If you mention low scores:

• Do it briefly and constructively.
• Focus on what you changed and how you’ve demonstrated improvement.

Example:

“Early in medical school, my standardized test performance did not reflect the clinical reasoning skills I was developing. I responded by restructuring my study approach, seeking mentorship, and emphasizing active learning. Since then, I have demonstrated steady improvement in my clinical rotations, research productivity, and performance on written examinations, and I continue to apply these strategies to my growth as a future orthopedic surgeon.”

The goal is to acknowledge, not dwell.

---

4. Maximize Clinical Exposure: Rotations, Auditions, and Networking

For applicants to orthopedic surgery with low scores, clinical face-time with programs can make or break your match odds.

4.1 Home Program: Your Launchpad

If your medical school has an orthopedic department:

• Do everything possible to build a positive reputation there.
• Goals:
  • Get to know residents and faculty early.
  • Join department conferences, journal clubs, and grand rounds.
  • Seek mentorship from at least 1–2 faculty who can advise your application strategy.
• Ask directly:
  • “Given my scores, how can I best position myself for orthopedic surgery?”
  • “Are there specific programs that you think might be a good fit for me?”

Your home institution is more likely than others to:

• Understand your full context (strengths, growth).
• Overlook weak scores if you have proven yourself for months in their system.

4.2 Away/Audition Rotations: Performance Over Paper

Away rotations are critical for orthopedic surgery residency applicants—especially those matching with low scores.

Ideal goals for away rotations:

• 2–3 audition rotations at programs where:
  • You realistically could match (mid-tier, community, and less well-known programs often more open).
  • Your home faculty or mentors have existing relationships.

On your audition rotations:

• Treat each day like a month-long interview:
  • Show up earlier than residents.
  • Read about every case and anatomy the night before.
  • Be dependable: carry the list, know the patients, follow up on labs and imaging.
• Be proactive, but not overbearing:
  • Ask how you can help in clinic and OR.
  • Volunteer for tasks without complaining.
• Demonstrate:
  • Technical curiosity: know instruments, ask focused questions in the OR.
  • Team orientation: help co-students, don’t compete in obvious ways.

Programs remember students who:

• Work hard without drama.
• Help the team run smoothly.
• Are enjoyable to work with at 3 a.m.

A strong away rotation can elevate you above your scores and even put you on the “interview no matter what” list.

4.3 Networking and Advocacy

Low-score applicants benefit disproportionately from:

• Mentors making personal calls or sending emails to program directors.
• Faculty saying: “You should really take a look at this applicant.”

To build toward that:

• Maintain regular contact with mentors.
• Share your evolving CV and list of programs you’re targeting.
• Ask directly but respectfully:
  • “Would you feel comfortable reaching out to any program directors on my behalf, especially at programs you know well?”

Many match stories with low Step 1 scores include some version of: “My mentor called the PD there and vouched for me.”

---

5. Application Strategy: Targeting, Volume, and Backup Plans

Even the best-prepared low-score candidate must apply smartly.

5.1 Program Targeting: Where You’re More Likely to Be Heard

As a low-score applicant, you should:

• Apply broadly in orthopedic surgery:
  • Academic, community, university-affiliated, and smaller programs.
• Consider:
  • States and regions that are less destination-driven.
  • Programs not at the very top of national rankings.

Helpful signals for more open-minded programs:

• Historically accepting applicants with mixed board performance.
• Strong emphasis on clinical training, operative volume, and mentorship.
• Less emphasis on pure research prestige.

How to research this:

• FREIDA and program websites: check resident backgrounds.
• Talk to current residents and recent grads from your school who matched.
• Ask your ortho faculty: “Which programs might be more holistic in their evaluations?”

5.2 Application Volume and Timing

With a low Step 1 or Step 2 score:

• Over-apply rather than under-apply:
  • Many ortho applicants apply to 60–80+ programs; being low-score, you should be prepared to be on the higher end of that.
• Submit as early as ERAS opens:
  • Late submission can hurt even high-score applicants.

Make sure:

• All your letters are uploaded on time.
• Your personal statement is tailored but not overly customized (you can have a few variants if needed: e.g., research-heavy vs. clinically-focused).

5.3 Considering Backup Plans Without Giving Up

You can still be fully committed to orthopedic surgery and simultaneously maintain rational backup strategies.

Options include:

1. Apply Ortho + Backup Specialties in Same Cycle

   • Particularly if your scores are very low and your advisors strongly recommend it.
   • Potential backup specialties:
     • General surgery
     • Physical medicine & rehabilitation (PM&R)
     • Internal medicine with a plan to pursue sports medicine or MSK-related fields
   • Risk: Some ortho PDs may sense divided focus if not carefully managed.

2. Preliminary Surgery Year

   • Apply to categorical ortho and also to prelim surgery spots.
   • Use prelim year to:
     • Excel clinically
     • Impress surgical and ortho faculty
     • Build more research
   • Then reapply to ortho with:
     • Strong clinical letters
     • Possibly better in-training exam performance.

3. Dedicated Research Year + Reapply

   • Commit to one research-intensive year in ortho.
   • Reapply with:
     • Stronger CV
     • Network support
     • Possibly a better Step 2 or other markers of improvement.

Choosing a backup doesn’t mean you’ve surrendered your ortho goal; it means you’re hedging intelligently while still pursuing Plan A.

---

6. Mindset, Resilience, and Execution

Low Step scores often bring shame, self-doubt, and comparison. That emotional load can sabotage your preparation if unmanaged.

6.1 Controlling the Controllables

You cannot:

• Rewrite your test history
• Force programs to overlook scores

You can:

• Optimize every future test and evaluation.
• Make every clinical experience count.
• Build genuine relationships with mentors and peers.
• Present yourself with honesty, humility, and confidence.

A practical approach:

• Create a timeline covering:
  • Step 2 CK/other exams
  • Research milestones
  • Rotations and away electives
  • Application drafting and review
• Revisit it monthly with a mentor.

6.2 Coping with Social Comparison

Within your class, you may see peers with high scores and multiple ortho interviews. Avoid the trap of:

• Constantly comparing your stats to others.
• Internalizing your worth as a future surgeon based solely on numbers.

Instead:

• Measure yourself against your own trajectory.
• Focus on specific behaviors:
  • How many hours did you put into quality studying?
  • Did you follow up with your research mentor this week?
  • Did you seek and incorporate feedback on your clinical performance?

6.3 Preparing for Interviews: Owning Your Story

When you do get interviews:

• You must be prepared to discuss your low Step score in a calm, constructive way.
• Practice answers to questions like:
  • “Can you talk about your Step performance?”
  • “What did you learn from that experience?”

Key elements:

• Brief acknowledgment
• Ownership (no blaming others)
• Concrete changes you made
• Evidence of improved performance or resilience

Example response:

“My Step 1 performance was not what I hoped for. I underestimated the volume of material and relied too heavily on passive review. After that experience, I met with faculty mentors, changed to an active question-based approach, and created structured daily schedules. I’ve since used that strategy on my clinical rotations, for Step 2, and for in-service-style exams, and I’ve seen consistent improvements in my scores and clinical evaluations. It was a difficult experience, but it forced me to become a more disciplined and deliberate learner.”

Practice with mentors or mock interviews until this feels natural, not rehearsed.

---

FAQs

1. Can I realistically match into orthopedic surgery residency with a low Step 1 score as an MD graduate?

Yes, it is possible, but the path is steeper and requires a deliberate strategy. Success typically depends on:

• A stronger Step 2 CK (if not already taken).
• Excellent clinical evaluations and audition rotations.
• Strong letters from orthopedic surgeons.
• Evidence of dedication to orthopedics (research, conferences, longitudinal involvement).
• Willingness to apply broadly and consider less competitive programs or geographic locations.

Each year, a subset of applicants with below average board scores match because they excel in other domains, especially away rotations and letters.

2. Should I take a research year to improve my chances for the ortho match?

A research year can be highly beneficial if:

• Your Step scores are significantly below the average ortho applicant.
• You currently have little to no orthopedic research.
• You can join a productive research group with strong mentorship.

A successful research year can:

• Strengthen your CV (publications, presentations).
• Help you build relationships with faculty who can advocate for you.
• Show long-term commitment to orthopedic surgery.

It is not mandatory for all low-score applicants, but it is often a powerful way to upgrade your application.

3. How many orthopedic surgery programs should I apply to with low scores?

Most competitive ortho applicants already apply widely (often 60–80+ programs). With low scores, you should expect to:

• Apply on the upper end of that range or beyond, depending on advisor recommendations.
• Include a mix of:
  • Academic programs
  • Community or university-affiliated programs
  • Programs in less competitive geographic regions

Discuss exact numbers with your home advisors, who can tailor their recommendations to your specific profile.

4. Should I apply to a backup specialty if my scores are low?

For some applicants, yes. Factors to consider:

• How low your scores are and whether you have any red flags (failures, repeats).
• Feedback from mentors and your home program’s ortho faculty.
• Your willingness to delay practice (research year, prelim year) versus pursuing a more attainable specialty now.

Some MD graduates apply to orthopedic surgery plus a backup specialty in the same cycle; others do an ortho-focused cycle first, then pursue prelim or research options if they don’t match. There is no single correct path, but the decision should be made with honest mentorship and a realistic understanding of your competitiveness.

---

If you’re committed to orthopedic surgery with a low Step score, your path will demand more planning, more persistence, and more willingness to seek feedback than most. But many residents now thriving in orthopedic surgery once sat where you are—facing disappointing exam results and deciding to fight for the career they wanted. With a thoughtful strategy and strong mentorship, you can still build a compelling, match-worthy application.