The State of Telemedicine, Telerehabilitation, and Virtual Care in Musculoskeletal Health: A Narrative Review

Abstract

Telemedicine has become an increasingly important component of musculoskeletal care, with recent advances in virtual physical examinations, enhanced patient education, and expanded access to treatment and telerehabilitation. Emerging applications of artificial intelligence, including virtual triaging and remote patient monitoring, promise to further augment telemedicine’s effectiveness and scope. Despite limitations and a continued preference for in-person visits among some patients, telemedicine can be a valuable tool for musculoskeletal health practitioners, offering new ways to deliver high-quality, timely, and cost-effective care.

Introduction

Telemedicine offers many advantages for musculoskeletal care, including enabling physicians to see patients outside traditional clinics or hospital settings and providing remote rehabilitation for both postoperative and nonoperative treatment protocols. Across all specialties, the adoption of telemedicine accelerated dramatically during the COVID-19 pandemic, and it has since become especially important to the delivery of musculoskeletal care. In 2020, U.S. hospitals saw a 75% surge in telemedicine encounters, rising from approximately 111.4 million to nearly 194.4 million in 2021 [16]. During this time, many orthopedic surgeons incorporated telehealth into their practices; Buchalter et al [6] found in a survey at one institution that over 90% planned to continue using telemedicine post-pandemic.

Given the high demand for musculoskeletal care [47], telemedicine is poised to play an increasingly important role in care delivery. This narrative review summarizes the current state and trends of telemedicine in orthopedics, highlighting areas that benefit from remote care, challenges to its implementation, and future innovations in virtual healthcare.

Methods

An electronic search of the PubMed database was performed using the following terms: (“telemedicine” OR “telehealth” OR “teleRehab”) AND (“outcomes” OR “cost” OR “patient perceptions” OR “challenges”) AND (“musculoskeletal” OR “orthopaedic” OR “orthopaedics” OR “musculoskeletal” OR “spine surgery” OR “hand surgery” OR “sports medicine”). Papers published in English between January 1, 2018, and February 16, 2025, were reviewed, yielding 653 articles. The final selection, achieved through consensus among the authors, focused on topics related to the delivery of telemedicine or telerehabilitation in orthopedic surgery or musculoskeletal health. Ultimately, 42 studies were included and discussed within the context of telemedicine care delivery, telerehabilitation, patient perceptions of telemedicine, financial considerations, challenges of telemedicine, and future directions.

Results

Telemedicine Care Delivery

With the growing adoption of telemedicine in orthopedic surgery, there has been increased awareness of learning to interact with patients in a virtual setting and recognizing the impact that this can have on patient care delivery [12]. While taking a virtual patient history is a straightforward process, performing a virtual physical examination may not be so intuitive; it requires a new way of thinking. In addition, physical exam tests vary across orthopedic subspecialties, each with different nuances and techniques. This has led to the development of telemedicine-specific examinations for both general musculoskeletal assessments [22] and subspecialty areas, including the elbow [24], hip [42], knee [21], shoulder [21], foot/ankle [43], hand [33], and orthopedic oncology [23] (Figs. 1 and 2).

Fig. 1.

Example of virtual shoulder examination with on-screen abduction range of motion measurements.

Fig. 2.

Example of virtual knee examination with on-screen range of motion measurements.

As an orthopedic subspecialty characterized by a high degree of perioperative consistency, total joint arthroplasty (TJA) has demonstrated significant progress in assessing the efficacy of telemedicine. In a pre-COVID-19 randomized controlled trial of TJA patients, Buvivk et al [7] found there was no difference between patients assigned to initial video consultation versus those who consulted in-person with regard to their perceptions or clinical outcomes following surgery. In addition, Baxter et al [3] showed the efficacy of virtual preoperative education for patients undergoing TJA, specifically patients classified as “high-risk” based on factors including race/ethnicity, comorbidities, and psychosocial/socioeconomic identity. The patients included in this study were not deemed eligible for ambulatory surgery and, as part of their institutional protocol, received individualized preoperative counseling and education via a face-to-face, video, or phone-based appointment. The authors showed that neither phone nor video formats were inferior to face-to-face visits and that patients who received video consultations were more likely to be discharged home and less likely to have a 30-day readmission compared to those who had a phone consultation. While selection bias may influence the results, due to patients self-selecting their care setting, it may also point toward differences in the effectiveness of telemedicine based on the method of delivery.

Within the field of spine surgery, a thorough physical exam is a critical component of a patient’s office visit and helps guide treatment. Prompted by assessment moving online during the COVID-19 pandemic, Iyer et al [15] developed a best practices technique for performing a spine physical examination using telemedicine, including modified methods of evaluating strength, sensation, and special testing such as straight leg raise, Spurling’s test, and tests for myelopathy. While many spine experts have been able to reach a consensus regarding their ability to provide safe and appropriate remote care for patients with lumbar stenosis, lumbar radiculopathy, and cervical radiculopathy, more work is needed to validate examinations for conditions such as cervical myelopathy [14]. Furthermore, Farid et al [10] evaluated telemedicine for screening patients with adolescent idiopathic scoliosis. The researchers demonstrated a high level of agreement between telehealth and in-person, spine-specific measurements such as the angle of trunk rotation. Patients and caregivers also responded favorably to satisfaction surveys regarding their overall experience and whether they would recommend this care to others. However, it should be noted that not all parameters were as reliably replicated using virtual visit types; differences were noted in assessments of pelvic and shoulder asymmetries. Also, it is not fully understood how an orthopedic surgeon’s ability to detect nuances in a virtual physical exam affects clinical care and outcomes; this warrants further study.

Telerehabilitation

Building on advancements in virtual care delivery, telerehabilitation has emerged as a key area of growth in musculoskeletal telemedicine. Lack of education and resources are among the most significant barriers to adequate postoperative rehabilitation—telemedicine represents an intriguing opportunity to help bridge this gap, allowing for easier access to skilled therapy regardless of a patient’s sociodemographic background or geographic location [44]. In addition, it may allow for increased flexibility, frequency, and duration of therapy time, which has been associated with faster return to sport, higher likelihood of return to the previous level of sport, and fewer long-term complications [48].

Postoperative telerehabilitation has been shown to be effective in patients undergoing TJA. Bettger et al [4] performed a randomized controlled trial with 304 patients undergoing total knee arthroplasty (TKA) and demonstrated similar functional outcomes (including knee range of motion and gait speed), fewer hospitalizations, and higher therapeutic compliance rates in patients randomized to home exercise programs. A retrospective study performed by Kuether et al [18] demonstrated similar findings, with no significant differences in 90-day readmission rates, ED visits, or need for manipulation under anesthesia (MUA); in fact, the telemedicine physical therapy group showed a larger improvement in patient-reported outcome measures compared to the in-person therapy group. In addition, Piqueras et al [35] reported greater quadriceps strength in patients randomized to interactive virtual telerehabilitation programs after TKA; these results were maintained at 3 months postoperatively. Correia et al [9] reported a greater knee range of motion at 8 weeks and 3 months following TKA, and a greater improvement in timed up-and-go tests at 3 months postoperatively after total hip arthroplasty (THA) in patients with remote rehabilitation powered by artificial intelligence (AI) and remote clinical monitoring. Overall, these findings demonstrate the effectiveness of telerehabilitation for patients undergoing TJA, with outcomes either equal to or surpassing standard rehabilitation programs. Similar findings have also been published in the sports medicine literature. Lim et al [25] performed a randomized control trial with 56 patients undergoing anterior cruciate ligament reconstruction; patients were randomized to receive either telerehabilitation or conventional in-person rehabilitation. Both groups demonstrated improvement in all outcomes over time, with no significant differences in patient-reported outcome measures (PROMs) and quadriceps strength at 6, 12, and 24 weeks, indicating the ability of telerehabilitation to reproduce the effectiveness of traditional rehabilitation programs in this patient population.

Telerehabilitation may also provide benefits to patients pursuing nonoperative treatment of orthopedic conditions. Zhang et al [50] performed a systematic review of 497 patients with rotator cuff injuries and demonstrated that patients who performed rehabilitation via telemedicine had significantly better shoulder range of motion, functional outcomes, and improvement in pain relative to traditional rehabilitation. Similarly, a randomized control trial by Tore et al [45] evaluated the use of remote rehabilitation for patients with knee osteoarthritis and demonstrated that patients who underwent rehabilitation by telemedicine had higher PROMs, treatment satisfaction, and improvement in pain scores relative to the control group.

Of note, there are few, if any, studies showing inferior outcomes with the use of telerehabilitation in orthopedics, though this could be a function of publication bias. Nevertheless, telerehabilitation certainly appears to be a noninferior method of delivering rehabilitation care for certain orthopedic procedures, with some evidence to suggest it may produce superior outcomes compared to conventional rehabilitation. While telerehabilitation may provide easier access to rehab programs for some patients, patient motivation and therapist commitment are likely required to obtain maximum benefit.

Patient Perceptions of Telemedicine

Patient buy-in is critical to the successful use of telemedicine. As such, it is imperative to understand how patients perceive its use. In a study performed prior to the COVID-19 pandemic, El Ashmaway et al [2] demonstrated that 90% of patients were either satisfied or very satisfied with virtual follow-up after elective TJA. This trend appears to be continuing with the increased adoption of telemedicine reported in a recent review by Chaudhry et al [8]. This article critically appraised 12 studies, 8 of which were randomized controlled trials, and found that there was no difference in patient satisfaction among those receiving orthopedic care by telemedicine and those receiving in-person care. More specifically, they found that 92% of patients receiving telemedicine care were satisfied with their treatment, showing no significant difference compared to those receiving in-person care. Similar findings have been reported in both the foot/ankle [20] and spine patient populations [5], suggesting that patients favorably view both telemedicine and in-patient visits, and are equally satisfied with telemedicine care across a wide range of orthopedic diagnoses.

Patient satisfaction may be directly correlated to clinical outcomes and length of visit. Silva et al [41] examined the effect of telemedicine on pediatric patients who underwent nonoperative treatment for type I supracondylar fractures or occult elbow injuries and found that there were no differences in clinical outcomes (fracture displacement, range of motion, and pain) or initial satisfaction based on visit type. However, there was a significant difference in the length of encounters, with a mean encounter length over the 4 weeks of treatment of 18 min in the telemedicine group versus 47 min in the in-person group, including wait time prior to the visit. When including travel to the appointment, the difference was even more striking (18 vs 111 min). Interestingly, when patients were alerted to the differences in time commitment, satisfaction dropped in the in-person treatment group once those participants realized they spent over twice the amount of time in the clinical encounter. Similar findings were seen in a study by Sathiyakumar et al [39], in which trauma patients were randomized to receive follow-up care in-person or through telemedicine. Although there was no difference in patient satisfaction, there was a significantly lower rate of patients needing to miss work for visits in the telemedicine group (0% vs 56%), and these patients also spent significantly less time at their visits. Nearly identical findings were reported by Kane et al [17] in patients who underwent rotator cuff repair. These studies speak to the benefits of telemedicine and describe how it can be used to optimize time for both patients and physicians.

While telemedicine may be a useful tool for clinical encounters, many patients still prefer in-person visits. In a study conducted by Manz et al [27], the authors found that after a virtual appointment, 90% of patients reported that they would utilize telemedicine again in some capacity, and 54% would prefer their next appointment to be in-person. Similarly, in a cohort of patients who underwent primary hip arthroscopy, there were no significant differences in patient satisfaction between those receiving care via telemedicine and those receiving it in person. However, 52% of the telemedicine group and 75% of the in-person group expressed a preference for in-office visits [40], with similar trends seen in patients undergoing shoulder arthroscopy [29]. This suggests that while many patients appreciate the advantages of virtual visits, including increased efficiency and the ability to avoid taking time off work, there remains a subset who prefer in-person visits.

Financial Considerations

Improved costs for both patients and the healthcare system are another potential benefit of telemedicine. A recent study by O’Donnell et al [34] examining the cost-effectiveness of telemedicine encounters in 49 patients after shoulder surgery demonstrated that virtual visits were 54% less costly ($49 vs $107) and 88% shorter in total visit time (9 vs 70 min) with demonstrably high patient satisfaction. This was also seen in a randomized control trial by Muschol et al [31] evaluating 52 patients after knee or shoulder surgery. In their analysis, telemedicine helped to reduce travel costs, time costs, and production loss to an average of $80 per patient. Similar results were shown by El Ashmaway et al [2] who demonstrated a 41% reduction in cost when using virtual methods for postoperative follow-up after elective TJA. In fact, 86% of their patients reported either a reduction in time or cost compared to previous in-person appointments. Early data suggest virtual care may also be cost-effective in the postoperative rehabilitation setting. For instance, McKeon et al [30] demonstrated that telerehabilitation was significantly less costly for patients undergoing TJA, with savings of between $206 to $4100 per patient.

Telemedicine may also help surgeons by directly improving clinical efficiency. In a randomized control trial of patients with either knee or shoulder conditions, the use of telemedicine led to shorter clinical contact times (4 vs 11 min) without a difference in patient outcomes. Increased efficiency also enabled surgeons to see more patients; assuming 2 h of telemedicine per week, it was estimated that surgeons could have 171 more patient encounters annually [32]. Furthermore, assuming 10% of visits were to be transitioned to virtual care, the authors estimated that senior physicians would experience annual savings of $80,275. Such increased efficiency could enable surgeons to provide additional care for a larger number of patients while also allowing for increased hospital or practice savings.

While telemedicine appears to have many economic benefits, there are studies that provide financial caution regarding its implementation. For example, in a retrospective study by Livingston et al [26]—which included patients from 3 high-volume academic joints, hand, and sports practices in the Midwestern United States—there was no difference in cost savings between virtual and in-person encounters. The researchers showed that while virtual visits consumed four fewer minutes of personnel time, surgeons spent longer on virtual visit activities (8 vs 6 min for in-person), with part of this difference being due to technical difficulties. This highlights a pitfall of telehealth in general: if the technology underpinning the visit is not fully functional, from either the provider or patient side, it can lead to a frustrating and inefficient clinical encounter.

Of note, Medicare coverage of telemedicine is not ensured to continue over the coming months and years. Coverage of telemedicine by Medicare was substantially increased in 2020 in response to the COVID-19 pandemic [46,48]. Since then, this increased coverage has been renewed consistently, including most recently before a March 31, 2025, deadline when the U.S. Congress passed a temporary extension until September 2025 [11]. However, its future is uncertain given the political climate and other factors relating to the U.S. government’s budget. If telemedicine is no longer funded at the same level for patient encounters by Medicare, other insurance carriers may follow suit, impacting the ability of clinicians to provide remote health care services for patients outside of already bundled payment structures.

Challenges With Telemedicine

Despite the demonstrated benefits of telemedicine, several challenges associated with virtual care have been identified, including ensuring equitable access to telemedicine across diverse racial and socioeconomic groups. A retrospective comparative study by Xiong et al [49] examined the demographics of new orthopedic patients during a 10-week period in 2019 and a similar 10-week period in the early pandemic. The results revealed disparities in access to telemedicine, with Hispanic and Asian patients less likely to have telehealth visits compared to White patients. In addition, patients insured through Medicaid were less likely to participate in virtual care than patients who were privately insured. Similar trends demonstrating lower telehealth utilization among minority and noncommercial insurance patients have been shown in several other studies performed across the country [1,38]. These studies underscore the importance of ensuring adequate access to telehealth care and working to understand potential barriers to access among patients from diverse sociodemographic backgrounds.

Another challenge to the implementation of telemedicine has been difficulty navigating technology. In a survey by Puzzitello et al [36], patients with lower income and poor health had increased difficulty using telehealth technology while seeking orthopedic care during the COVID-19 pandemic. In addition, non-White patients and those with governmental insurance were more likely to report inadequate care or technical difficulties after telemedicine visits in pediatric orthopedic and sports medicine practices [13]. In addition, Mao et al [28] conducted a mixed-methods needs assessment of older adults in two independent living facilities and discovered that one of the top barriers for both sites was the participants’ lack of familiarity with telemedicine technology. Unfortunately, these studies suggest that low-income patients, patients with chronic conditions, and older adults—all groups who could benefit the most from access to virtual care—have not been able to utilize telehealth with ease. Moving forward, it may help to streamline remote clinical encounters by developing specific telehealth protocols (including the assessment of patients’ telehealth capabilities and preferences), providing clear step-by-step written instructions for how to access the appointment, and having a process for on-demand support for troubleshooting technological issues.

Future Directions

In addition to telehealth and virtual care delivery, there are likely health care changes on the horizon due to the continued development of large language models (LLMs) and AI. One area that has shown promise is the use of LLM-based chatbots to triage, create differential diagnoses, and generate treatment plans for certain musculoskeletal presentations. Kunze et al [19] evaluated the use of an LLM chatbot to appropriately triage patients presenting with various causes of knee pain. They showed that ChatGPT-4 provided reasonable diagnoses to triage patient complaints that were generally consistent with the differential diagnoses provided by sports medicine physicians. This could serve as an augment for patient triage, potentially allowing for better identification of patients who may benefit from an in-person versus virtual visit.

Additionally, AI can play a role in enhancing the virtual care experience. Ramkumar et al [37] explored the use of AI to remotely monitor patients recovering from knee arthroplasty, arthroscopy, and anterior cruciate ligament reconstruction through Bluetooth-enabled devices. They used an AI-based algorithm to aggregate the mobile health data with mobility, range of motion, patient-reported outcomes, opioid consumption, wound appearance, and rehabilitation compliance. This represents a possible role for AI in helping to assess real-time patient information for virtual monitoring of a patient’s progress. Further development and validation of these tools in clinical settings will help augment the virtual patient experience and improve musculoskeletal care delivery in parallel with telemedicine and virtual health care delivery.

Conclusion

While certain elements of an orthopedic surgery practice require in-person evaluation, there is undoubtedly a growing role for telemedicine and virtual care in musculoskeletal health delivery. This review demonstrates increasing research on virtual healthcare as well as on the incorporation of remote clinical evaluation tools, remote encounters, and virtual rehabilitation programs into a musculoskeletal health practice. Further validation of the clinical effectiveness of these tools and their possible financial benefits will help guide the continued widespread adoption of remote musculoskeletal care delivery.