Navigating Orthopedic Surgery Residency with Low Step 1 Scores

Orthopedic surgery is one of the most competitive specialties in the Match. When you’re aiming for an orthopedic surgery residency with a low Step 1 score or below average board scores, it can feel like the odds are stacked against you. They are harder—but they are not zero.

This guide will walk you through a realistic, step‑by‑step strategy to stay in the game, build an outstanding application, and maximize your ortho match chances despite weaker scores.

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Understanding the Challenge: Scores in Orthopedic Surgery

Orthopedic surgery residencies receive far more applications than they can seriously review. Program directors often use USMLE/COMLEX filters as an initial screen, especially for Step 1 (for older cohorts) and Step 2 CK.

How Programs View Low Scores

Key points about a low Step 1 score in orthopedic surgery:

• Step 1 (numeric) historically matters
  Old data suggest average matched ortho residents often had scores in the 240s–250s+. If you’re <230, it’s considered below average for this specialty. For those with a low Step 1 score (or a fail on first attempt), programs may worry about:

  • Risk of failing in‑training exams
  • Risk of failing Step 2 or Step 3
  • Ability to pass the ABOS boards

• Step 2 CK is now critical
  As Step 1 moves to pass/fail, Step 2 CK has become a key numeric metric. A strong Step 2 CK can partially offset a weak Step 1 and reassure programs.

• COMLEX for DO students
  Many ortho programs prefer or require USMLE in addition to COMLEX. A below average COMLEX score may be more challenging if you also don’t have USMLE, because programs are less familiar and can’t benchmark as easily.

• One low score vs. a pattern
  Big difference between:

  • One low Step 1 score with strong Step 2, strong clinical grades, and strong narrative support
  • A pattern of multiple low scores or failures (Step 1, Step 2, in‑training, exam retakes)

Programs are risk‑averse, but they are not uniformly rigid. Some will consider applicants with low scores if the rest of the application tells a compelling story of resilience, growth, and clear fit for orthopedics.

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Step 1: Brutally Honest Self‑Assessment and Goal Setting

Before you plan how to match with low scores, you need to know exactly where you stand and what is realistically possible.

1. Map Out Your Academic Profile

Write down:

• USMLE/COMLEX:
  • Step 1 (or pass/fail status; if numeric, include)
  • Step 2 CK / COMLEX Level 2
  • Any failures or multiple attempts
• Preclinical performance:
  • Pass/fail vs graded, any failures or repeats
• Clinical performance:
  • Honors/High Pass in core clerkships (especially Surgery, Medicine)
  • Orthopedic or surgical subspecialty rotations grades
• Class rank or quartile, if available
• Research:
  • Total number of projects
  • Orthopedic-specific vs non‑orthopedic
  • Published vs in progress vs ideas only
• Other:
  • Leadership roles, teaching, sports background, military, unique skills

This gives you a 360º “portfolio” of strengths and weaknesses beyond your low Step score.

2. Clarify Your Realistic Match Probability

Factors that improve your chances despite a low Step 1 or below average board scores:

• Strong Step 2 CK (or Level 2) significantly higher than Step 1
• Honors in Surgery and strong ortho rotation evaluations
• Multiple ortho research projects, ideally with publications or presentations
• Strong relationships with orthopedic faculty who will advocate for you
• Home ortho program that knows and trusts you
• Willingness to apply broadly, including less “name‑brand” or community programs
• Flexibility geographically and in program type (university vs community)

Factors that worsen your chances:

• Multiple exam failures (Step 1 + Step 2, or repeats of the same exam)
• Weak clinical evaluations, professionalism issues
• Late interest in ortho without a track record (no research, no electives)
• Significant red flags (leaves, remediation, disciplinary actions)

Use this reality check to refine your strategy—maybe for some applicants that means designing a two‑cycle plan (e.g., research year then apply), not just “send more applications and hope.”

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Step 2: Turn Scores from Weakness to Story

If you’re matching with low scores, your job is not to hide them (you can’t), but to contextualize them and show growth.

1. Crush Step 2 CK (or Level 2)

If your Step 1 is low and Step 2 CK is still ahead:

• Treat Step 2 as your redemption exam
  Aim to outperform your Step 1 by a significant margin—at least 10–15+ points. That signals improvement and trajectory.

• Adjust your approach:

  • Analyze what went wrong with Step 1 (content gaps, test anxiety, timing, burnout).
  • Build a new prep strategy: NBME/COMSAE baseline, consistent study schedule, Qbank‑heavy approach, weekly self‑assessment.
  • Seek help early: tutoring, learning specialists, or faculty mentors.

If Step 2 is already low as well:

• Focus on strengthening every other dimension: research, clinical excellence, letters, story.

2. Reframe the Narrative in Your Application

Your personal statement and sometimes your MSPE/Dean’s Letter or advisory letter can address your low score. The goal: accept responsibility, show growth, and move on.

Avoid:

• Making excuses or blaming others.
• Long emotional stories that center the score rather than your trajectory.

Do:

• Briefly acknowledge the low score or failure (if needed).
• Offer concrete evidence of improvement:
  • Better performance on Step 2
  • Honors in clinical rotations after Step 1
  • Remediation efforts (study strategies, counseling, wellness changes)
• Connect this growth to traits valued in orthopedic surgery:
  • Resilience
  • Work ethic
  • Coachability
  • Discipline

Example (concise) framing for a personal statement:

“Early in medical school, I struggled with test‑taking and underperformed on Step 1. That result was a wake‑up call. I met with learning specialists, redesigned my study strategies around active recall and spaced repetition, and committed to a more disciplined schedule. Since then, I have honored both my surgery and orthopedic rotations, and improved my performance on Step 2 CK. That experience taught me how to respond to setbacks—skills I now use daily in the OR and on the wards.”

You are showing programs:
“Yes, my Step 1 was low. No, I am not high‑risk; here’s why.”

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Step 3: Build an Ortho‑Focused Application That Outshines the Numbers

Orthopedic surgery is a “fit” and relationship‑heavy specialty. When your board scores are weak, everything else must be exceptional.

1. Clinical Performance and Rotations

Your performance on surgery and orthopedic rotations can mitigate low scores:

• Aim for Honors (or equivalent) in:

  • Surgery clerkship
  • Orthopedic sub‑internships
  • Possibly Medicine (shows work ethic and reliability)

• On every ortho rotation, act like a sub‑I:

  • Show up early, be prepared, read before cases.
  • Volunteer for tasks and follow through meticulously.
  • Be a team player: help juniors, support PAs and nurses.
  • Avoid being a “score‑focused” student; be patient‑ and team‑focused.

• Sub‑internships (“aways”):

  • With a low Step score, away rotations become critical:
    • They allow you to bypass the initial score screen by letting faculty know you personally.
    • Solid performance can lead to strong letters and active advocacy.
  • Strategy tips:
    • Do an away at your home program if available and at 1–2 other programs where your school or mentors have connections.
    • Choose places where your Step 1 filter is less likely to block you—often mid‑tier academic or community programs, smaller programs, or ones with a reputation for valuing work ethic and personality.
    • Treat each away as a “month‑long interview.”

2. Letters of Recommendation: Your Strongest Weapon

With below average board scores, you need stellar letters that explicitly vouch for your clinical strength, reliability, and readiness.

Aim for:

• 3–4 orthopedic surgery letters, including:
  • One from your home program chair or program director, if possible.
  • One from a faculty you worked closely with (clinic/OR) who can describe your day‑to‑day performance.
  • One from an away rotation faculty who can discuss how you compare to their usual sub‑Is.

Strong letters will:

• Describe you as indispensable on the team.
• Use comparative language (“top 10% of students I’ve worked with in 10 years”).
• Highlight:
  • Work ethic and resilience
  • Technical aptitude
  • Ability to learn quickly and accept feedback
  • Communication with patients and staff
  • Professionalism and reliability

Your job is to:

• Earn these letters through excellent performance.
• Ask faculty directly:
  “Do you feel you can write a strong letter of recommendation for my orthopedic surgery application?”
  If there is hesitation, seek someone else.

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Step 4: Leverage Research, Networking, and Strategic Program Selection

When scores are a weakness, research and relationships become even more important for the ortho match.

1. Ortho Research: Depth over Just Numbers

Your goal is to demonstrate commitment to the field and academic potential:

• Start research as early as possible:
  • Connect with your home orthopedics department.
  • Ask to help with retrospective chart reviews, database studies, case reports, or systematic reviews.
• For those late to ortho:
  • It’s still possible to start now—just be honest about your timeline and availability.

Emphasize:

• Productivity: abstracts, posters, podium presentations, publications.
• Continuity: working with the same mentor over time.
• Responsibility: taking ownership of data collection, IRB submissions, or manuscript drafting.

If your scores are particularly low or you have exam failures:

• Consider a dedicated research year:
  • Ideally within your home ortho department or at a major academic center.
  • Aim to:
    • Produce multiple projects
    • Build strong relationships
    • Gain hands‑on clinical and OR exposure
  • This can significantly improve your ortho match chances—even for applicants with low Step 1 scores—by turning you into a known commodity to a department.

2. Networking: Let People Know You (And Your Story)

Orthopedic surgery is a small world. A personal advocate can help programs look past cutoffs.

Tactics:

• Mentor relationships:

  • Find at least one senior ortho faculty member who truly knows you.
  • Meet regularly to update them on your progress and seek honest feedback.
  • Ask for advice on program list, away rotations, and whether your plan is realistic.

• National and regional meetings:

  • Present posters or attend conferences like AAOS, specialty societies, or resident research days.
  • Introduce yourself professionally:
    • “I’m a medical student interested in orthopedics, working with Dr. X on [topic]. Would you have a few minutes to talk about your program and what you look for in applicants?”
  • Don’t lead with “I have a low Step 1 score—can I still match?”
    Lead with curiosity, professionalism, and contributions.

• Program outreach (carefully):

  • Avoid mass, generic emails.
  • If you have a legitimate connection (research, a shared mentor, prior away rotation), it’s appropriate to:
    • Let them know you applied.
    • Express genuine interest.
    • Mention any updates (new publication, improved Step 2, etc.).

3. Strategic Program Selection: Where Low Scores Hurt Less

Not all programs weigh scores equally. Some are more open to matching applicants with low scores who demonstrate excellence elsewhere.

Consider:

• Home program:
  • Always your best shot—faculty know you beyond your Step scores.
• Programs with a reputation for valuing work ethic:
  • Often strong community programs or smaller academic programs.
• Programs that have historically matched DOs or IMGs:
  • Often more flexible about traditional metrics.
• Geographic flexibility:
  • Some regions are relatively less competitive (e.g., certain Midwest or South programs vs big coastal cities).
• Apply broadly:
  • With low scores, expect to apply to a large number of programs (often 70–80+), budget permitting.
  • Use your mentors’ knowledge to target places where your application is most likely to be read.

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Step 5: Executing the Match Strategy – Application, Interview, and Backup Plans

Once you’ve optimized your profile, you need to deploy a smart, realistic strategy for the orthopedic surgery residency match.

1. Writing a Coherent Application

Pieces must tell a unified story:

• Personal Statement:

  • Emphasize:
    • Why orthopedics (specific moments, not generic “I like bones”).
    • Long‑term goals (academic vs community, sports vs trauma, etc.).
    • Qualities you bring to surgery teams: discipline, teamwork, manual skills, grit.
  • Briefly address low scores if necessary, and pivot to your growth.

• Experiences Section:

  • Highlight leadership, sports, military, engineering, manual crafts—anything that showcases teamwork and technical aptitude.
  • For each, emphasize responsibilities and impact, not just titles.

• Research Section:

  • Separate ortho‑specific and non‑ortho, but both matter.
  • Make sure each entry is accurate about your role and status (submitted, accepted, in press, published).

2. Interview Performance: Outworking Your Scores

Once you have interviews, your low Step 1 or below average scores matter less; your performance in these settings becomes critical.

Key goals:

• Professionalism and likability:

  • Be on time, prepared, engaged.
  • Show humility and coachability.

• Clear explanation of your journey:

  • Use a concise “story” if asked about your scores:
    • What happened
    • What you changed
    • How you improved
    • What you learned that will make you a stronger resident

• Demonstrate fit for orthopedic culture:

  • Team‑oriented, hardworking, “no‑drama,” resilient.
  • Show that you handle long hours and stress in a healthy way.

Practice with:

• Mock interviews with advisors or residents.
• Behavioral questions (“Tell me about a time you failed…”) and scenario‑based questions.
• “Red flag” discussions (low scores, leaves, etc.) framed with accountability and growth.

3. Backup and Parallel Plans

Even with perfect strategy, orthopedic surgery residency remains highly competitive. For some with very low or multiple failing scores, the probability of matching into ortho in a single cycle may be small.

Consider parallel plans:

• Extended Timeline / Second Attempt:

  • Take a research year, strengthen application, reapply.
  • Use SOAP in the first cycle if you go unmatched, then regroup.

• Preliminary Surgery Year:

  • Apply to general surgery prelim positions as a backup.
  • Perform exceptionally; some ortho programs do occasionally pick up strong prelims.
  • Be aware: this is not guaranteed to convert to an ortho spot.

• Alternative but related fields:

  • PM&R, sports medicine pathways, interventional pain, or non‑operative musculoskeletal medicine.
  • You can still work closely with orthopedic patients and sports populations.

Deciding between full commitment to ortho vs early parallel planning is best done with honest input from mentors who know your entire record and your local match environment.

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FAQs: Matching into Orthopedic Surgery with Low Scores

1. What is considered a “low Step 1 score” for orthopedic surgery?

Numerically, for cohorts with scored Step 1, many matched ortho applicants historically scored in the mid‑240s and above. A Step 1 score in the low 220s or below is typically viewed as low for this specialty, especially at highly competitive programs. That said, with Step 1 moving to pass/fail, programs are placing more emphasis on Step 2 CK, clinical evaluations, research, and letters.

2. Can a high Step 2 CK offset a low Step 1 in ortho?

Yes—to a meaningful extent, especially if the gap indicates improvement (e.g., Step 1: 218 → Step 2: 245+). A strong Step 2 suggests:

• You can master complex clinical content.
• You are less likely to struggle with in‑training exams and board certification later.

It doesn’t erase your Step 1, but it helps program directors reframe you as a lower‑risk applicant, especially when combined with strong clinical performance and letters.

3. Is an orthopedic research year worth it if I have below average board scores?

For many applicants with low Step 1 or Step 2 scores, a well‑structured ortho research year can be extremely beneficial. It can:

• Expand your publications and presentations.
• Provide daily contact with faculty and residents.
• Generate strong letters and real advocacy.
• Give you clinical exposure (clinic, OR, call) that reinforces your commitment.

However, it must be:

• Well‑supervised by faculty genuinely invested in your success.
• Focused on productivity and relationship building.
• Part of a realistic overall plan, not a guarantee of matching.

4. Should I still apply ortho if I have a Step 1 failure?

It depends on the full context:

More favorable:

• Single Step 1 fail, passed on second attempt with a clear upward trend (and stronger Step 2).
• No other failures or professionalism issues.
• Strong clinical performance, ortho research, and powerful letters.
• Willingness to apply broadly, take a research year, or consider prelim surgery.

Less favorable:

• Multiple failures (e.g., Step 1 and Step 2).
• Weak clinical evaluations and no ortho exposure.
• Limited openness to geographic flexibility or backup options.

Discuss with trusted ortho mentors and your dean’s office. In some cases, a parallel specialty may provide a more secure path while still allowing you to work in musculoskeletal care.

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Matching into orthopedic surgery with a low Step 1 score or below average board scores is undeniably challenging—but not impossible. The key is to stop focusing solely on “the number” and start strategically building everything around it: your clinical excellence, your research record, your relationships with mentors, and a narrative that shows resilience and growth.

With deliberate planning, relentless work ethic, and honest mentorship, you can still give yourself a fighting chance in the ortho match—and, if necessary, craft fulfilling alternative pathways in musculoskeletal medicine.