Musculoskeletal conditions are a major cause of dis- ability in the United States and consequently are respon- sible for considerable health-care expenditures.51 Epidemiologic studies have found significant variations in the per-capita rates of hospital admissions and surgical procedures in almost all fields of medicine including orthopedics.* These variations in utilization and expendi- ture are curious because they occur in nearby communi- ties that seem to be otherwise similar.