OBJECTIVES: The objective of the study is to compare care pathways of patients with musculoskeletal (MSK) complaints-from first presentation in primary care to referral and follow-up in rheumatology-across 5 European healthcare systems, and to explore how healthcare system characteristics influence these pathways. METHODS: Routinely collected healthcare data from 5 European countries (UK, Sweden, the Netherlands, Spain, and Hungary) were analysed. Primary care data included > 4 million adults with at least 1 MSK encounter, and secondary rheumatology data included > 600,000 patients. Primary care consultation rates, referral rates to specialist care, and rheumatology follow-up duration were compared across countries. Healthcare characteristics were extracted from the literature. RESULTS: The distribution of MSK complaints in primary care was similar across countries, with 25% to 30% of residents visiting their general practitioner annually for an MSK complaint (UK data not available). In contrast, referral of such patients with MSK complaints to rheumatology varied considerably (5%-38%). Among those referred, 46% to 70% were discharged within 3 months, whereas only 13% to 43% remained in long-term rheumatology care. We observed that countries with a high proportion of sustained long-term rheumatology care (UK and Sweden) had lower referral rates, fewer rheumatologists per capita, and employed a selective triaging system, whereas countries where referrals more frequently resulted in short-term rheumatology care (the Netherlands, Spain, and Hungary) had higher referral rates and employed nonselective triaging. CONCLUSIONS: Substantial cross-country variation exists in the management of MSK complaints. Although primary care MSK presentations are similar, referral rates and the patient-mix reaching rheumatology differ widely between countries-an important consideration for developing cross-national clinical guidelines and diagnostic tools.