For patients with musculoskeletal complaints x-rays are usually not need unless there are red flags present. This means that the vast majority of patients do not need x-rays.
What are red flag?
Red flags are when the patient’s history or examination point to possible serious conditions. Examples of red flags include:
A history of trauma
Neurologic findings on the examination
Current unexplained Fever
Serious medical conditions such as cancer
A history of recent onset bowel or bladder dysfunction
When there are no red flags present x-rays are not needed to commence a trial of care. In fact x-rays can be detrimental.
How can x-rays be detrimental?
Anyone who is over the age of 20 will have some type of degeneration that can be seen on x-rays. Degeneration however is essentially a gray hair of the spine. Degenerative findings are natural parts of aging and are not a reason to worry. The vast majority of time not they are not the source of pain. When people see these changes on imaging it has been shown that it worsens their outcomes. Believing that there is something wrong with your spine has quantifiable detrimental effects.
Are there other times when x-rays or MRIs should be ordered?
If a patient does not respond to a trial of conservative care then it is appropriate to take imaging. In many cases this means at least one month of treatment with either no positive changes or potentially even some negative changes. In those cases imaging, such may be of use.