I am in support of the Virginia Board of Physical Therapy's recent guidance on diagnostic imaging referrals.  

When dealing with musculoskeletal pain syndromes, Physical Therapists are professionally qualified to gather a thorough history and perform a detailed physical examination when deciding whether diagnostic imaging is needed.  

Physical Therapists are often the first healthcare provider to diagnosis tendonipathathies. Having the ability to request a musculoskeletal diagnostic ultrasound image can: have a significant impact on clinical outcomes; provide a cost-effective and low-risk alternative to advanced imaging such as MRI or CT scan; screen for urgent conditions - deep vein thrombosis, fracture, tendon rupture; and enhance patient-clinician engagement by meeting patient's expecations provding visual information of the problem.  

On behalf of APTA Virginia, the state chapter of the American Physical Therapy Association representing physical therapists, physical therapist assistants, and students across the Commonwealth, I appreciate the opportunity to comment on Guidance Document 112-1, Guidance on Diagnostic Imaging Referrals by Physical Therapists, adopted August 20, 2026. APTA Virginia supports the Board’s interpretation that Virginia law does not prohibit a licensed physical therapist from referring a patient to an appropriate practitioner for diagnostic imaging. We encourage the Board to maintain this interpretation and support its clear communication to physical therapists, imaging providers, and other healthcare professionals.

Improving Timely Access to Appropriate Care

Physical therapists routinely evaluate patients experiencing musculoskeletal pain, injuries, and functional limitations. During these evaluations, a physical therapist may identify clinical findings that warrant diagnostic imaging to inform appropriate patient management or further medical evaluation. When a physical therapist cannot directly facilitate access to imaging, patients may incur out-of-pocket expenses through appointment co-pays, require additional office visits, and face unnecessary administrative steps, delays in diagnosis, and avoidable barriers to care.

Permitting physical therapists to refer patients to appropriate imaging practitioners when clinically indicated would streamline the diagnostic process, improve coordination across healthcare settings, and support timely, evidence-informed clinical decision-making. These benefits are particularly important for patients who already encounter challenges accessing healthcare services, such as those living in rural communities or medically underserved areas. Facilitating appropriate referrals can help patients receive the care they need without unnecessary delays while preserving the role of physicians and other qualified practitioners in medical diagnosis and treatment.

Alignment With Physical Therapy Education and Contemporary Practice

Diagnostic imaging is not an unfamiliar topic in physical therapy. The Commission on Accreditation in Physical Therapy Education has required entry-level physical therapist programs to include content and learning experiences on diagnostic imaging since 2016. Many entry-level physical therapist education programs have incorporated imaging-related content for more than 20 years, preparing physical therapists to recognize when imaging may be indicated, understand its relevance to clinical decision-making, and identify findings that warrant further medical evaluation. Physical therapists are educated to recognize the limits of their scope of practice and refer patients appropriately when additional evaluation is needed.

Virginia would not be breaking new ground by recognizing the ability of physical therapists to refer patients for diagnostic imaging. As of March 2026, 11 states and the District of Columbia expressly permit physical therapists to order imaging through statutes, regulations, board rules, policies, or opinions. These jurisdictions demonstrate that imaging referrals by physical therapists are compatible with established regulatory frameworks, with some jurisdictions incorporating additional requirements for training, communication, or reporting.

Additionally, physical therapists serving in the U.S. military have long had authority to order imaging studies within their practice settings. These experiences further demonstrate that imaging-related clinical decision-making is an established component of physical therapist practice when supported by appropriate education, clinical judgment, and professional accountability.

Patient Safety, Scope of Practice, and Financial Responsibility

APTA Virginia recognizes the importance of protecting patients and maintaining clear professional boundaries. The Board’s guidance appropriately distinguishes referring a patient for diagnostic imaging from personally using imaging equipment or medically diagnosing disease or injury. A referral does not authorize a physical therapist to perform imaging studies or expand the physical therapist’s authority to medically diagnose disease or injury. Rather, it allows the physical therapist to facilitate evaluation by an appropriate practitioner when imaging is clinically warranted.

To our knowledge, there is no established evidence demonstrating that permitting appropriately educated physical therapists to refer patients for diagnostic imaging is inherently unsafe or fiscally irresponsible. Regulatory decisions should be grounded in evidence, patient safety, and the potential to improve access to appropriate care. Financial incentives also warrant consideration. Under the proposed framework, physical therapists do not perform the imaging studies themselves, and they cannot own or operate imaging equipment and perform the imaging services. Accordingly, the referral authority under consideration does not provide a financial incentive to generate imaging procedures for personal profit. The clinical rationale for a referral should remain the patient’s presentation, examination findings, and need for further evaluation.

Conclusion

APTA Virginia appreciates the Board’s thoughtful review of Virginia law and its recognition that physical therapists may refer patients to appropriate practitioners for diagnostic imaging. This interpretation supports contemporary physical therapy practice and offers a practical opportunity to reduce unnecessary barriers to timely, appropriate healthcare.

We encourage the Board to affirm and clearly communicate this guidance while recognizing the distinction between referring patients for imaging, performing imaging procedures, and medically diagnosing disease or injury. Clear guidance will help physical therapists, imaging providers, and other healthcare professionals work collaboratively to improve patient access, promote efficient care delivery, and protect the health and well-being of Virginians.

Thank you for your consideration and for your continued commitment to public protection and high-quality healthcare in the Commonwealth.

Respectfully,

Emily Hawkins, PT, DPT, Ph.D.

President, APTA Virginia