The aims of this study were to identify: (1) whether an after-hours emergency department (ED) collaborative care service using primary contact physiotherapists (PCPs) improves treatment times for musculoskeletal and simple orthopaedic presentations; and (2) differences in orthopaedic referral rates and analgesia prescription for patients managed by PCPs compared with secondary contact physiotherapists.A prospective observational study was conducted of diagnosed, matched patients seen in a 4-day week after-hours ED primary contact physiotherapy service in a tertiary referral ED. Patients presenting with a musculoskeletal or simple orthopaedic diagnosis reviewed by a physiotherapist as either the primary or secondary physiotherapy contact between 1630 and 2030 hours from Saturday to Tuesday were included in the analysis. Outcome measures collected included ED length of stay, orthopaedic referrals in the ED, follow-up plan on discharge from the ED and analgesia prescriptions.There were no adverse events, missed diagnoses or re-presentations for any patients managed by an ED PCP. Mean (±s.d.) treatment time for patients seen by an ED PCP was 130±76min, compared with 240±115min for those seen by a secondary contact physiotherapist (P<0.001). There were significant differences between patients managed by PCP versus secondary contact physiotherapists, with decreases of 20.4% for referrals to orthopaedics in the ED, 21.2% for orthopaedic clinic referrals on discharge and 8.5% in analgesia prescriptions for patients managed by an ED PCP (P<0.001). In addition to these reductions, there was a 17.5% increase in general practitioner referrals on discharge for patients managed by an ED PCP (P<0.001).An after-hours ED physiotherapy service is a safe service that reduces ED treatment times, as well as analgesia prescriptions and orthopaedic referrals for patients managed by a PCP.PCPs are capable of providing safe and effective care to patients in the ED who present with musculoskeletal complaints. Patients managed by physiotherapists as the primary contact require fewer X-rays and have reduced treatment times.Compared with previously published articles, this study demonstrates similar reductions in ED treatment times in an after-hours setting for patients managed by an ED PCP. However, this was achieved by physiotherapists who have less reported experience. Furthermore, this study found that management of patients by PCPs resulted in a reduction in the amount of analgesia prescribed and orthopaedic input required for these patients.PCPs can be trained to operate in the ED with minor or no prior ED experience while facilitating reductions in the amount of analgesia prescribed, orthopaedic referrals required (in ED and on discharge) and reducing treatment times for patients.