Choose Wisely: Do You Really Need an X-ray?

  •   August 2, 2018
  •  Nancy Littke, PT

X-rays have been invaluable to health care since they were discovered in the late 1800s. While they may be considered “routine practice” by some, they have also been shown to pose a potential health risk due to exposure to radiation.1 High doses of radiation exposure may increase cancer risk. The tests may also reveal “incidental findings” - changes that are unrelated to the reason the test was ordered, but which often lead to needless worry and unnecessary follow-up tests and procedures, such as injections or sometimes even surgery.2

Choosing Wisely Alberta is part of a Canadian movement to help patients, physicians, and other health-care providers engage in conversations about tests, treatments, and procedures that have been identified as being of low or no value to inform patient-care decisions. The campaign highlights practices that patients and physicians should question. Routinely ordering x-rays for low back pain is a practice that the campaign has highlighted as being of low or no value.2

But I have significant back pain, shouldn’t I have an x-ray?

Studies have shown that 95% of back pain is categorized as “non-specific low back pain.”3 This means the pain or stiffness cannot be attributed to a specific cause, structure or disease.

Most episodes of low back pain resolve within a couple of weeks without any treatment.2

As part of their assessment, health-care professionals, including physiotherapists, take a thorough history and complete a physical exam. They do so to answer important questions that help determine if there is a clear “cause” for pain and to look for warning signs.

Signs or “red flags” that may require urgent investigation and treatment include:2

  • A history of cancer
  • Unexplained weight loss
  • Fever
  • Recent infection
  • Loss of bowel or bladder control
  • Abnormal reflexes, or loss of muscle power or feeling in the legs

If none of these signs are present, an x-ray is not indicated. Instead, self-care measures are recommended, which may include:2

  • Staying active
  • Using heat to relax muscles
  • Considering the use of over-the-counter medications such as pain relievers or anti-inflammatories.
  • Finding positions that allow comfortable rest and sleep
  • Talking to a health-care professional if symptoms do not improve in a few days or if symptoms worsen.

I did have an x-ray and it shows I have Degenerative Disc Disease – that’s really serious, right?

Despite the name, Degenerative Disc Disease (DDD) is not actually a disease.

DDD is a condition related to the normal wear and tear of spinal discs in the neck and back.4 Picture intervertebral discs as gel-filled cushions between the vertebrae, that are there to provide shock absorption and flexibility in our spine. As we age these discs gradually lose moisture and height, narrowing the space between the bony vertebra. With less cushioning from the discs, there is increased stress on the bone surfaces that causes changes to the bones. These changes are known as osteophytes (bony outgrowths or spurs) and are visible on an x-ray.

Research has shown that these changes in the spine are common, usually develop slowly over time, and often don’t correlate with symptoms of pain or stiffness.

  • Up to 77% of people under 50 years of age and more than 90% of people over 50 show evidence of DDD on MRIs.4
  • From 37% of 20-year-olds to 96% of 80-year-olds show these changes without ever having pain in their neck or back.5

In other words, changes in x-rays don’t automatically relate to pain and would not change treatment recommendations, including self-management.

Will an x-ray tell me if I have arthritis?

When people talk about arthritis, they are usually referring to osteoarthritis (OA). OA is a gradual wearing down of joint cartilage and changes to bone that can cause pain and stiffness. Although there are other types of arthritis, OA is by far the most common and affects millions of people worldwide.6 Knees, hips, hands, and the spine are the joints most commonly affected.

As we age and use our joints, the firm, rubbery and slippery cartilage that covers the ends of bones breaks down and wears away. This can result in the swelling, pain, and stiffness in the joints. Eventually, the bone surfaces themselves start to break down and develop osteophytes like in DDD. These changes to the cartilage and bone also occur slowly. Studies show that 88% of the time middle age or elderly people have joint changes on x-ray even when there are no previous complaints of knee pain. Individuals may experience the pain and stiffness associated with OA well before changes show up on x-ray.

Therefore, it is important that diagnosing OA and planning the appropriate treatment be based on the assessment and the effects on daily function rather than an x-ray. An x-ray alone will not identify the presence or absence of osteoarthritis and may, in fact, do harm. An incorrect diagnosis can lead to inappropriate treatment, increased worry about causing or worsening symptoms, decreased activity and overall loss of function.

Treatment for pain and stiffness in any joint should be aimed at managing symptoms, making changes in lifestyle to avoid damage to the joint, and assisting individuals to keep fit and active. The desired outcome is to maintain or improve function and to prevent or postpone the need for surgical interventions such as joint replacements.

I have shoulder pain, so I should have an x-ray, right?

  • Up to 6% of the population consults their health-care provider every year with complaints of shoulder pain
  • The lifetime probability of experiencing shoulder pain is as high as 67%
  • Subacromial pain disorder (SAP) is responsible for up to 85% of shoulder pain-related medical visits8

SAP symptoms include pain in and around the shoulder itself and may be caused by injury or overuse of soft tissues such as muscles or ligaments. X-rays do not provide a clear picture of soft tissues, they are of limited value in determining treatment plans for SAP.

As with DDD, there is a high possibility that any bony changes noted on the x-ray are not the cause of symptoms and may have been present long before the current problem occurred.8

A physiotherapist will complete a thorough clinical exam that looks at the history of the problem, other possible sources of pain and what specific movements or positions reproduce the pain. This can provide the information needed to confirm the source of the problem and develop an appropriate treatment plan. If the physiotherapist has concerns that something more serious is going on they will recommend further evaluation and/or investigation.

In summary

X-rays have an appropriate time and a place. However, for most non-traumatic problems the value of a diagnostic image is quite limited and; therefore, these images are not needed. Conservative, non-invasive management addressing pain and loss of function is often the first step. Overuse of diagnostic imaging is costly for the health system, but more importantly, it leads to unnecessary exposure to radiation, often leads to additional unnecessary tests and treatments, and can create unnecessary worry. Consult a physiotherapist if you are having joint pain. Your physiotherapist will complete an assessment to rule out the need for diagnostic imaging (rule out “red flags”) and can provide you with treatment for your symptoms. If diagnostic imaging is advised, many physiotherapists have the authorization to order it directly. If not, they will refer you to a medical colleague who can.

Click here to find a physiotherapist.


  1. Rehani B. (2011) Imaging overutilisation: Is enough being done globally? Biomedical Imaging and Intervention Journal;7(1):e6. doi:10.2349/biij.7.1.e6.
  2. Alberta Health Services (2017) Choosing Wisely Alberta Low Back Pain Toolkit. Choosing Wisely Alberta; Choosing Wisely Canada. Available at https://www.albertadoctors.org/Choosing%20Wisely/cwa-low-back-pain-toolkit.pdf Accessed July 23, 2018.
  3. Jarvik, J & Deyo, R. (2002). Diagnostic Evaluation of Low Back Pain with Emphasis on Imaging. Annals of internal medicine. 137. 586-97. Available at http://annals.org/aim/article-abstract/715687/diagnostic-evaluation-low-back-pain-emphasis-imaging Accessed July 24, 2018
  4. M. Teraguchi, N. Yoshimura, H. Hashizume, S. Muraki, H. Yamada, A. Minamide, et al (2014) Prevalence and distribution of intervertebral disc degeneration over the entire spine in a population-based cohort: the Wakayama Spine Study, Osteoarthritis and Cartilage, Volume 22, Issue 1, 104-110, https://doi.org/10.1016/j.joca.2013.10.019 Accessed July 10, 2018.
  5. Brinjikji W, Luetmer PH, Comstock B, et al. (2015) Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. American Journal of Neuroradiology.36(4):811-816 http://www.ajnr.org/content/36/4/811.long Accessed July 10, 2018.
  6. Mayo Clinic Patient Care & Health Information: Osteoarthritis. Available at https://www.mayoclinic.org/diseases-conditions/osteoarthritis/symptoms-causes/syc-20351925 Accessed July 12, 2018.
  7. Guermazi A, Niu J, Hayashi D, Roemer FW, Englund M, Neogi T, et al. (2012) Prevalence of abnormalities in knees detected by MRI in adults without knee osteoarthritis: population based observational study (Framingham Osteoarthritis study) BMJ 345: https://www.bmj.com/content/345/bmj.e5339  Accessed July 12, 2018.
  8. Cadogan A, McNair PJ, Laslett M, Hing WA (2016) Diagnostic Accuracy of Clinical Examination and Imaging Findings for Identifying Subacromial Pain. PLoS ONE 11(12): e0167738. https://doi.org/10.1371/journal.pone.0167738 Accessed July 10, 2018