Effective Strategies for US Citizen IMGs with Low Step Scores in Orthopedic Surgery

Orthopedic surgery is one of the most competitive specialties in the Match—and being a US citizen IMG with a low Step score can feel like starting at a disadvantage. But “competitive” is not the same as “impossible.” Every year, candidates with below average board scores find strategic ways to stand out and successfully match into orthopedic surgery residency programs.

This article focuses on practical, high-yield strategies specifically for a US citizen IMG or American studying abroad in orthopedics who is worried about a low Step 1 score or Step 2 CK. You’ll learn how to realistically assess your chances, plug gaps in your application, and build a compelling narrative that convinces program directors to look past the numbers.

---

Understanding the Challenge: Low Scores and US Citizen IMG Status

As a US citizen IMG or American studying abroad, you occupy a unique position. Programs may see you differently from non‑US IMGs because:

• You are usually US-culturally fluent and more likely to stay in the US long‑term
• You often have fewer visa concerns (or none)
• You may have connections in the US (home state, prior college, family in medicine)

Yet the combination of orthopedic surgery residency + IMG + low Step scores magnifies risk in the eyes of program directors. Understanding this allows you to build a more targeted strategy.

What counts as a “low” Step score?

With Step 1 now pass/fail, most “low score” concern focuses on Step 2 CK and any prior Step 1 failures. For ortho, programs often expect:

• Step 2 CK: Many matched ortho applicants have >250; IMGs who match are often even higher.
• “Below average board scores” in this context means:
  • Step 2 CK in the 230s or low 240s or lower
  • Any failed attempt on Step 1 or Step 2 CK
  • Substantially below your school’s mean or national mean

This doesn’t mean you cannot match. It means:

• You must overperform in other domains (clinical performance, research, letters, networking)
• You must show clear upward trajectory and resilience
• You may need a longer runway (extra research year, transitional year, or backup plan)

---

Step 1: Honest Assessment and Strategic Positioning

Before you build a plan, you need a precise diagnosis of your situation.

Key questions to ask yourself

1. Scores and attempts

   • Did you pass Step 1 on the first attempt?
   • Any step failures?
   • What is your Step 2 CK score and how does it compare to:
     • NRMP averages for ortho (US MD/DO and IMG)
     • Your school’s mean

2. Timeline

   • When do you plan to apply?
   • Do you have time for:
     • A dedicated research year?
     • Additional US clinical experience (USCE)?
     • Step 3 before application?

3. Your “assets”

   • Do you have any US letters from orthopedic surgeons?
   • Any orthopedic research (abstracts, posters, publications)?
   • Any significant leadership, sports, or manual-skill activities (e.g., college athletics, carpentry, mechanical hobbies) that fit the ortho culture?

4. Your constraints

   • Financial limits (can you support an unfunded research year?)
   • Geographic limits (are there US regions/states you strongly prefer/need?)
   • Visa or immigration issues (if dual citizenship or complex status)

This honest audit helps you decide:

• Whether to apply directly to orthopedic surgery
• Whether to delay a year for strengthening your application
• Whether to apply ortho plus backup specialties
• How aggressively to invest in research and networking

---

Step 2: Academic Recovery — Turning Low Scores into a Narrative

You cannot erase a low Step score, but you can reframe it and counterbalance it.

1. Dominate Step 2 CK if you haven’t taken it yet

If your Step 1 score is low (or you barely passed) and Step 2 CK is pending:

• Treat Step 2 CK as your redemption exam.
• Aim for a score that is clearly above the national mean, ideally into the mid‑240s or higher, even if that’s ambitious.

Actionable strategies:

• Take a full NBME assessment early to identify weaknesses.
• Build a tight schedule: UWorld x1–2 passes + NBME + practice tests under exam conditions.
• Take Step 2 only when your practice scores are consistently at or above your goal.

A low Step 1 + high Step 2 CK is far more favorable than two low scores.

2. Consider Step 3 strategically

For a US citizen IMG with below average Step scores, a solid Step 3 (if you have time before the Match you’re targeting) can:

• Show academic progression and remediation of earlier weaknesses
• Increase confidence that you’ll pass boards on time during residency
• Help with states/programs that value early Step 3, especially if they’ve had residents struggle with exams

But only take Step 3 if:

• You are well‑prepared and likely to score competitively, not just to “get it over with.”
• Your clinical knowledge is fresh (e.g., after a sub‑I, prelim year, or research with strong clinical involvement).

3. Optimize your transcript and school performance

Orthopedic programs look beyond test scores:

• Clerkship grades (especially surgery, medicine, and orthopedics)
• Honors in sub‑internships (sub‑Is)
• Dean’s letter/MSPE narrative, including comments on professionalism, work ethic, and technical skill

If you can:

• Re‑take or repeat key rotations where your performance was weaker.
• Ensure your orthopedic electives highlight your strengths and give you opportunities for strong letters of recommendation (LORs).

4. Craft a clear “comeback” story

In your personal statement and interviews, be prepared to explain:

• Why your Step scores were low (brief, honest, non‑defensive)
• What you changed: study strategies, time management, wellness, resource use
• How your later performance (clinical grades, research output, Step 2/3, letters) shows a sustained upward trend

Programs are more willing to look past matching with low scores when they clearly see:

“This applicant had a rough start, analyzed it, fixed it, and is now consistently performing at a high level.”

---

Step 3: Building a Compelling Ortho Profile Beyond Scores

For a US citizen IMG targeting orthopedic surgery residency with a low Step 1 score or below average board scores, the rest of your application must scream: “I am 100% committed to orthopedics and I will be an asset to your program.”

1. US Clinical Experience (USCE) in Orthopedics

USCE is critical—not just any USCE, but orthopedic-focused USCE.

Aim for:

• At least 2–3 orthopedic electives in the US
• A sub‑internship (sub‑I) at a program where:
  • IMGs are not automatically filtered out
  • You know they have historically interviewed or matched IMGs
  • You can work closely with faculty, not just shadow

On rotation:

• Be early, prepared, and visible.
• Volunteer for call, consults, presentations.
• Learn the OR culture: anticipate needs, respect sterile fields, know instruments, practice knot-tying.
• Ask for specific feedback and incorporate it quickly.

Your goal is to become:

“That IMG student who worked harder than anyone else, was great with patients, and got along with the team.”

This is how you earn powerful LORs that can offset low scores.

2. Letters of Recommendation that Actually Move the Needle

For low-score applicants, letters are not optional—they are central.

You want:

• 3–4 strong letters from:
  • US orthopedic surgery faculty
  • Preferably at academic centers that routinely participate in the ortho match
  • Ideally at least one letter-writer who is well-known or active in national societies

What a strong letter should say:

• You are trusted in the OR and on the wards
• You demonstrated rapid growth and teachability
• You show resilience, work ethic, and ownership of patient care
• The writer would be comfortable having you as a resident in their program

How to get such letters:

• Ask early: “Dr. X, I’m planning to apply for orthopedic surgery. If I work hard and continue to improve, would you consider writing a strong letter for me?”
• Provide:
  • Your CV
  • A summary of your work with them (patients you followed, projects, presentations)
  • A draft of your personal statement (if ready)

3. Orthopedic Research: Depth Over Tokenism

For a competitive, numbers‑weak ortho applicant, research is often the difference between screened-out and interviewed.

Options:

1. Dedicated research year in orthopedics (most powerful)

   • Join an ortho lab or research group at a US academic center.
   • Aim for:
     • Multiple abstracts/posters at meetings (AAOS, AOA, subspecialty meetings)
     • At least a few manuscripts submitted/published
     • Meaningful involvement (data analysis, writing, presenting), not just your name on a list.

2. Part-time research while in school

   • Collaborate remotely with US mentors.
   • Focus on smaller, faster projects (retrospective chart reviews, case series, systematic reviews).

3. Quality matters

   • Better to have 3–4 substantial projects where you can discuss your role clearly than 15 superficial ones.

As a US citizen IMG, a research year may also:

• Get you known by a department that can vouch for you
• Yield strong mentor letters
• Provide networking with attendings and residents who can advocate for interviews

---

Step 4: Application Strategy — Where and How to Apply

With low scores, strategy and targeting matter as much as content.

1. Understand realistic odds, but don’t self‑eliminate

Orthopedic surgery is statistically tough for IMGs, especially with low scores. But US citizen IMGs often have slightly better odds than non‑US IMGs, particularly if:

• They have strong US orthopedic letters
• They train in schools with existing US partnerships
• They demonstrate clear academic recovery

Your question is not “Can anyone with my numbers match ortho?” but:

“What is the most realistic pathway for me to maximize my odds of landing an ortho spot—now or in the future?”

2. Program selection: Where low-score US citizen IMGs have a chance

Key targets:

• Programs that have previously matched IMGs, especially US citizen IMGs
• Community-based ortho programs or smaller university-affiliated programs
• Programs in less competitive geographic regions (Midwest, certain South or rural areas)
• Newer or expanding programs that may be more open to non-traditional pathways

How to research:

• Use FREIDA, NRMP Charting Outcomes, and program websites to see history of IMG acceptance
• Look at resident rosters to identify:
  • Any IMGs
  • Any graduates from Caribbean or international schools
  • Former US citizen IMG or American studying abroad profiles

Avoid:

• Programs that explicitly state “We do not sponsor visas or do not consider IMGs”—even if you're a citizen, a no‑IMG culture is a red flag.
• Ultra-elite programs that historically only match top‑tier US MDs with stellar scores (unless you have a very strong connection or major research at that institution).

3. Apply broadly and early

For low-score US citizen IMGs, a typical ortho match application strategy might include:

• 80–120+ orthopedic programs, depending on budget and competitiveness of the rest of your file
• Submission on day 1 of ERAS opening—no delays
• Polished, specialty-specific personal statement and CV

You might also consider:

• Applying in two cycles if you improve your profile substantially (e.g., after a research year)
• Parallel applications to selected backup specialties (see below)

4. Parallel Planning: Backups Without Losing Sight of Ortho

As important as your dream is, your long‑term plan must also be realistic.

Common backup strategies for ortho‑focused US citizen IMGs:

• Preliminary surgical year (prelim gen surg)

  • Allows you to gain strong clinical evaluations and US letters
  • Opportunity to reapply to ortho during or after
  • Some transitions from prelim gen surg to categorical ortho do occur, but they’re rare and highly dependent on local opportunities and your performance.

• Research year → reapply ortho

  • If you don’t match, convert next year into a stronger application with research and networking.

• Related surgical specialties (e.g., general surgery, PM&R, neurosurgery, plastic surgery)

  • Only if you can genuinely see yourself being satisfied in these fields. Don’t choose a backup you’ll resent.

The key is to be:

• Emotionally committed to ortho
• But intellectually honest about risk and flexible with timelines

---

Step 5: Communication, Networking, and Interview Performance

With low scores, every human interaction with a program carries extra weight. You must be memorable—in the right way.

1. Use your US citizen IMG identity as a strength

As an American studying abroad, highlight:

• Your understanding of the US healthcare system and culture
• Your motivation to return and serve particular communities (e.g., your home state, underserved areas)
• Any US-based experiences before med school: college, EMT, scribe, athletic trainer, research assistant, etc.

In your personal statement and interviews, you might frame:

“I chose to train abroad knowing it meant taking a more challenging path back to the US. That decision required resilience, adaptability, and independence—traits I’ve brought into every clinical experience and now to my pursuit of orthopedic surgery residency.”

2. Thoughtful networking (without being pushy)

Ways to connect:

• Attend orthopedic conferences (local, state, national) and introduce yourself to faculty.
• Reach out to ortho departments for:
  • Research opportunities
  • Observerships or short rotations
  • Calls or Zoom meetings to discuss their program and your goals

Best practices:

• Keep emails brief, respectful, and specific.
• Attach a 1‑page CV.
• Avoid asking for “a favor” in the first contact; ask for advice or opportunities to contribute.

Programs are more likely to take a chance on a low-score applicant who is:

• Known to them
• Has worked or researched with them
• Comes with strong internal advocates

3. Interview mastery: How to talk about low scores

You will almost certainly be asked about your Step scores. Prepare:

• A concise, honest explanation (20–30 seconds)
• A focus on:
  • What you learned
  • How you changed your approach
  • Evidence of sustained improvement

Avoid:

• Blaming the exam, your school, or external events as the sole cause
• Over‑sharing personal details unless they are central and you’re comfortable discussing them
• Sounding rehearsed without authenticity

Example framing:

“Early in medical school, I underestimated how differently I needed to study for board-style questions. My Step 1 performance reflected that. Afterward, I met with faculty, analyzed my test breakdown, and completely changed how I prepare: I increased question-based learning, practiced time management, and focused on weak systems. That process led to substantial improvement in my clinical rotations and Step 2 CK, and I’ve maintained those habits. While I’m not defined by one test, it pushed me to become a more disciplined and reflective learner.”

Then pivot quickly to your strengths (USCE, research, letters, work ethic).

---

Bringing It All Together: A Realistic Roadmap

For a US citizen IMG pursuing an orthopedic surgery residency with a low Step 1 score or below average board scores, a realistic multi‑year plan might look like:

Year 3–4 of med school (or earlier if you’re already past this stage, adapt accordingly)

• Maximize core rotation grades (especially surgery).
• Find orthopedic mentors and join research projects.
• Prepare seriously for Step 2 CK to show academic improvement.

Final year of med school

• Do 2–3 ortho sub‑Is/electives in the US where IMGs are welcomed.
• Earn strong US letters from orthopedic attendings.
• Complete and present research if possible.
• Start networking with programs that have matched US citizen IMGs before.

If you do not match or feel underprepared
Option 1: Research year in ortho (highly recommended for low-score candidates)

• Full-time research at a US academic center.
• Multiple ortho projects, publications, and national presentations.
• Deep networking within that department.

Option 2: Preliminary surgery year

• Outstanding clinical performance, strong evaluations and letters.
• Reapply with more US experience and, if appropriate, Step 3 completed.

Through all phases:

• Maintain professionalism and humility—reputation travels fast in ortho.
• Keep backup plans in view without abandoning your primary goal.
• Regularly solicit feedback from mentors who know ortho and understand the IMG landscape.

You are not the only US citizen IMG with a low Step score who wants to match orthopedics—and some in your position do succeed. Those who do typically:

• Accept reality early
• Overcorrect with research, USCE, letters, and performance
• Use their “non-traditional path” as proof of grit and persistence, not as an apology

---

FAQ: Low Step Score Strategies for US Citizen IMG in Orthopedic Surgery

1. Can a US citizen IMG with a low Step 1 score realistically match into orthopedic surgery?
Yes, but the bar is high and the path is usually longer. Your chances improve if you can show:

• Significant improvement on Step 2 CK (and possibly Step 3)
• Strong US-based orthopedic rotations and letters
• Orthopedic research and visible commitment to the field
• A well-targeted application list focusing on programs that have historically taken IMGs

You should plan for contingencies (research year, prelim surgery year, or backup specialty) while still aiming for ortho.

---

2. Is it worth taking a research year as a US citizen IMG with below average board scores?
For orthopedics, yes—often very worth it, especially if:

• Your Step 2 CK is not clearly competitive
• You lack US ortho letters or research output
• You can join a well-connected ortho department that actively mentors research fellows

A productive research year can:

• Generate publications and presentations
• Provide powerful letters and advocates
• Demonstrate long-term interest and persistence in orthopedics

---

3. How many orthopedic programs should I apply to with low scores as a US citizen IMG?
Plan to apply very broadly, often 80–120+ programs, depending on:

• How low your scores are
• The strength of your USCE, letters, and research
• Your financial limits

Prioritize:

• Programs with a history of interviewing or matching IMGs, especially US citizen IMGs
• Less geographically competitive regions
• Programs where you have rotated, researched, or have connections

---

4. Should I apply to a backup specialty if I’m determined to do ortho?
It’s wise to have a parallel plan, especially if your scores are well below typical ortho ranges. Options include:

• Applying orthopedic surgery + prelim general surgery
• Considering related surgical or musculoskeletal fields (e.g., PM&R with sports/MSK focus) if you can genuinely see yourself content there
• Planning for a research year and reapplying if you don’t match the first time

Your choice depends on your risk tolerance, financial situation, and willingness to extend training. Discuss your strategy with trusted ortho mentors who understand both your profile and the current ortho match landscape.

---

By combining honest self-assessment, strategic remediation, and a relentless focus on orthopedic-specific experiences, you can greatly improve your chances of an ortho match—even as a US citizen IMG with low Step scores.