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Background: The ability of primary care Extended Scope Physiotherapists (ESPs) to refer appropriate patients to secondary care has not been adequately examined. Also referrals for shoulder surgery from secondary care ESPs have been shown to be misdirected in comparison to other specialties. Barriers to referral have not been investigated but the literature suggests that referral criteria may improve appropriate referrals. The high prevalence of rotator cuff disease, its impact on pain and disability, and the lack of agreement between surgeons about when to operate indicate that there is a strong case for the development of surgical referral criteria for rotator cuff tear pathology. Method: The thesis has three stages of study. First a national survey of 99 primary care ESPs was undertaken to determine conversion to surgery rates, barriers to referral and the use of referral criteria. Secondly a national Delphi study with 20 shoulder surgeons was undertaken and surgical referral criteria for rotator cuff tear were developed. Thirdly after development, the criteria were tested on a convenience sample of 9 ESPs using 3 vignette case studies. Results: Primary care ESPs have a mean conversion rate of 74%. There was not enough data to show differences between subspecialist groups. Most barriers to specialist referral were associated with commissioning rather than issues pertaining to the primary care environment. 50% of ESPs reported using referral criteria which may explain why barriers to referral were relatively low. Surgical referral criteria for rotator cuff tear were developed. Key areas of consensus were: severity of pain, functional limitation, identification of fat atrophy and agreement for a trial of physiotherapy before referral. When referral criteria were piloted on a surgical candidate 33% of the ESPs changed their referral behaviour appropriately. Conclusion: ESPs in primary care have shown mean conversion rates of 74%. Surgical referral criteria to improve the appropriateness of rotator cuff tear referrals have shown promising results when piloted. Implications: In future referral criteria may have the potential to improve the appropriateness of rotator cuff referrals and may be beneficial as a benchmark against which ESPs can independently demonstrate the appropriateness and quality of the care they provide.