X-rays vs. MRI’s, Part 1 of 3: Do I really need x-rays?

Note: This is the first post in a three-part series discussing the use of x-rays and MRI’s in an orthopaedic sports medicine practice. There seems to be a good deal of confusion among the general public and physicians as well about when to order x-rays and/or an MRI. I expect that this series and the underlying premise (x-rays are very helpful and should be routinely ordered, while MRI’s are utilized far too frequently) will not be a universally accepted opinion. I would like for the reader to understand the basic concept of each test in order to understand why their physician orders tests to evaluate sports injuries.

One of the questions I’ve frequently get in the office when I’m evaluating a patient for a new sports injuries is whether or not I need to order x-rays. To answer that I need to explain why many people don’t feel like they are necessary. As you may or may not know, x-rays just show bones. They don’t show soft tissue structures like the tendons, ligaments, meniscus in the knee, muscles, cartilage, etc. Many people correctly assume that their injuries are soft tissue in nature, such as a rotator cuff tear, ligament tear, or meniscus tear. While they may be right, we often request that patients have x-rays taken either during or prior to their orthopaedic office visit. Sometimes patients question the need for x-rays as they don’t feel that there is a broken bone and therefore would have x-rays that would not show anything abnormal. Unfortunately, x-rays are necessary to the orthopaedic surgeon for making the correct diagnosis.

X-rays are important for at least three reasons. First, there may be findings on the x-rays that may make more advanced study such as an MRI unnecessary. One of the best examples I can give of that is obtaining knee x-rays when evaluating for a possible tear of the ACL. While it’s true that the anterior cruciate ligament is only seen on an MRI and not on an x-ray, secondary bony findings can be seen. For instance, if there’s a small piece of bone pulled off the lateral tibial plateau (the top of the shin bone towards the outside of the knee), that finding implies that the ACL is torn and very likely makes an MRI unnecessary.

Another reason that we order x-rays is that they occasionally show findings that we weren’t expecting but that are important. Without sounding too alarmist, I can count numerous examples both from my practice and other colleague’s examples where tumors and other serious findings were found on x-rays when these were not the expected findings. For instance, a high-school female athlete could present for evaluation of a snapping sensation in the front of her hip. This would likely be a tendon snapping across the front of the hip and likely of no significance. Despite the fact that I would not expect the x-rays to show any pathology because a tendon does not show up on an x-ray, I would order them to make sure there were no other findings. As I said earlier, I can unfortunately imagine a scenario where she could have a lesion in the femur at the hip joint, necessitating referral to an orthopaedic oncologist. The x-rays hopefully would help to catch it early, potentially preventing a much more serious problem.

Joint space narrowing
Note the bone-on-bone joint space narrowing of the left knee.

Finally, x-rays can show us the status of the joint involved. For instance, in people with meniscal tears, especially adult athletes, it can be helpful to know if there are ny coinciding degenerative changes in the knee. The x-rays might show joint space narrowing and bone spurs that would imply that there are advanced degenerative changes that might affect not only the diagnosis but treatment outcome.

If there’s ever a question of whether or not x-rays are necessary, you should always ask either the office staff or the doctor himself to determine what studies are necessary and important.

Tweet this question about x-rays.

Read all three part of this series.
X-rays vs. MRI’s, Part 2 of 3: Do I need an MRI?
X-rays vs. MRI’s, Part 3 of 3: Are primary-care providers ordering too many MRI’s?

10 Responses to X-rays vs. MRI’s, Part 1 of 3: Do I really need x-rays?

  1. I had a serious fall August 1, 2013 my fall was documented and 12 days later I was in my Joint Replacement Drs. office. I had falling from against the wall and fell on my left side,ie., L-Hip, L-Leg, L-Shouldler and hit my the side of my face as well. I iced constantly daily to relieve swelling, there was some discoloration on my L-arm and hip and slight red redness on L-side of my face. I was given an X-ray that clearly showed a long crack on my L-Hip my doctor than did a split screen with X-rays he had taken approx. 2001/2002 the area at that time was just a clouded area. the new X-ray clearly showed a long crack. I was terrified I already have a total R-Hip Replacement, Total R-Hip Replacement, a Uni-Compartment L-Knee Replacement. The same day I was given my X-rays I was immediately given an MRI which did not show the long crack I had just seen however the MRI did show some Fibroid turmors (I am grateful for this) I am totally confused. My doctor now says there is evidence of some arthritic changes. Before I went to MRI I did cry and tell my surgeon that I emotionally did not feel that I could go through another Hip Replalcement at this time and he told me that he did not necessarily want to do one either, I was relieved. Since the hospital is next door to his office he told me that if the MRI picked up the the fracture(crack he/I both saw) to stay at the hospital and wait for him….the MRI did not pick up the long fracture and I left with the typed results of no fracture and have not heard from him since. Before I left his office to go to MRI he did tell me to stay on moderate bed rest, which I have until I saw my pain specialist and he advised me to put my walker in front of me as I sit on the bed and pull myself up a couple times a day and continue with my hot showers which always help me/joints. On 2/18//2011 I was going down
    steps in my home when I felt a severe stabing on my right side and I immediately fell butt first on the 4th step the intensity of fall that hard threw me against the wrought iron portion of the left rail and my Left arm went through the wrought iron bars but I kept falling with my arm still stuck in the rail I landed on the second step but my L-arm was still pinned above my head my son was able to jump over my head to the landing at the bottom of the steps to release my arm. My fingers immediately began to swell and 5 hours later my entire arm had turned rainbow colors black, red, blue in a few areas we began to ice and several hours later I was in my surgeons office having a sever torn rotar cuff tear and muscle tears I fell on this arm again on 8/1/2013…it is still soar. I am confused why did we see the crack in my L-Hip and the MRI did not pick up?

    • I’m sorry. As it says in many places in my blog, I cannot offer specific advice since I am not involved in your care. And without seeing the studies, I can’t offer any explanations or answers to your questions. Your surgeon should be able to answer those questions, though.

      • Hi , i had low back pain , dr prdered spinal mri + lumbosacral x ray
        M just ciourious if wasnt mri enough? Is xray sometimes better than xray? I did both tests n nothing revealed! Ill really appreciate your answer dear dr

  2. Three years ago I had an MRI of my knee because my doctor suspected a meniscus tear. The finding were that I had severe arthritis (cysts, bone spurs, severely worn cartilage etc.). Fast forward to today I am experiencing life altering knee issues. My orthopedic ordered x-Rays before he would see me. The report findings from my x-Rays show I have “mild” tricompartmental arthritis. How is this possible? I know MRIs show more but these findings have me baffled. Shouldn’t an X-ray show severe arthritis too. I am quite certain I did not get better in the last 3 years and I am aware that osteoarthritis is a degenerative progressive disease.
    Thanks for any insight you can offer.

    • I can’t say. Yes, generally osteoarthritis radiographic changes do not improve. It is possible that x-rays taken in different ways, such as standing vs lying down, could appear differently.

  3. I fell on my kneecap, causing a great deal of swelling, bruising and pain in that area. I went to the ER and had an X-ray. It showed no fracture but they put me in a knee immobilizer because of the fall history and physical exam. If the x-ray is clear, then nothing is wrong…right? This could just be a soft tissue injury?

    • Negative x-rays almost always mean the patient has no fracture. It does not necessarily rule out a soft tissue injury or ligament, tendon, cartilage, or other structural injury.

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david-headshot I am an orthopaedic surgeon and sports medicine specialist in Charleston, South Carolina.

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