Do I Need a Scan for My Back, Knee, or Shoulder Pain?

Many people with musculoskeletal pain (back, knee, or shoulder) wonder whether they need a scan like an X-ray, MRI or ultrasound to “see what’s wrong.” It’s a very reasonable question. After all, scans feel scientific and definitive.

But the latest research shows that imaging isn’t always necessary and often doesn’t change how we treat pain. In fact, routine scanning for common pain problems is not recommended unless there are specific reasons (Jenkins et al., 2021; Bussières et al., 2018).

A recent systematic review of clinical practice guidelines (which summarised 31 guideline statements) concluded that (Jenkins et al., 2021):

Routine diagnostic imaging for non-traumatic back, knee or shoulder pain should be discouraged. Imaging should be reserved for cases where there is suspected serious pathology (e.g., fracture, cancer, infection) or where imaging results are expected to change clinical management.

This review followed established methods (PRISMA), making it a robust piece of evidence guiding practice.

Why Scans Don’t Always Help Pain Outcomes

Many people have “abnormalities” without pain

Studies show that features like disc degeneration in the back, meniscal tears in the knee, and rotator cuff changes in the shoulder are common in people with no symptoms at all. These findings can show up on MRI but don’t necessarily explain a patient’s pain or predict outcomes (Brinjikji et al., 2015, Culvenor et al., 2019; Teunis et al., 2014).

For example:

• Back pain: MRI findings of “degeneration” are common even in pain-free adults.

• Knee scans: Meniscal tears are frequently found on MRI in older adults who have no knee pain.

• Shoulder scans: Rotator cuff changes often increase with age, even without symptoms.

This means a scan can show abnormalities that aren’t actually the cause of your pain, leading to confusion and unnecessary treatment.

Large clinical guidelines recommend against routine imaging for non-specific pain because (Jenkins et al., 2021; Bussières et al., 2018):

• It does not improve recovery or function for most people.

• It can increase anxiety or beliefs that something is “wrong” when the pain could resolve with conservative care.

• It may lead to unnecessary interventions.

One guideline summary showed that the routine use of imaging has been increasing, even though most patients with back, knee, or shoulder pain do not benefit from it (Jenkins et al., 2021).

When Scans Are Helpful

There are specific situations where imaging should be considered:

1. Red flag signs

If you or your therapist suspect something serious, imaging is appropriate. Examples include:

• Significant trauma (e.g., after a fall)

• Signs of infection

• Suspected fracture

• Severe neurological symptoms (e.g., progressive weakness or loss of bowel/bladder control)

In these cases, imaging guides urgent decisions.

2. No improvement with treatment

   If you’ve been following an active rehabilitation plan (exercise, education, activity modification) for a reasonable period and are not improving, imaging may be useful to see whether something specific is going on that alters your treatment path.

   
   

3. Pre-operative evaluation

   When surgery is being considered, imaging is often necessary to confirm the diagnosis and plan the operation.

So What Should You Do?

✔ If your pain is recent and you have no serious symptoms…

You probably do NOT need an immediate scan.

Instead:

• Start with a physical assessment

• Focus on movement, strength and activity modification

• Track your response to targeted rehabilitation

  
  

Getting the right care starts with a thorough assessment and an active plan, not automatic imaging.

References

Bussières, A.E., Stewart, G., Al-Zoubi, F., Decina, P., Descarreaux, M., Haskett, D., Hincapié, C.A., Pagé, I., Passmore, S., Srbely, J. and Stuber, K., 2018. Spinal imaging in low back pain: a systematic review of clinical practice guidelines. Journal of Orthopaedic & Sports Physical Therapy, 48(4), pp.265–281. https://doi.org/10.2519/jospt.2018.7555

Brinjikji, W., Luetmer, P.H., Comstock, B., Bresnahan, B.W., Chen, L.E., Deyo, R.A., Halabi, S., Turner, J.A., Avins, A.L., James, K. and Wald, J.T., 2015. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. American Journal of Neuroradiology, 36(4), pp.811–816. https://doi.org/10.3174/ajnr.A4173

Culvenor, A.G., Øiestad, B.E., Hart, H.F., Stefanik, J.J., Guermazi, A. and Crossley, K.M., 2019. Prevalence of knee osteoarthritis features on MRI in asymptomatic uninjured adults: a systematic review and meta-analysis. British Journal of Sports Medicine, 53(20), pp.1268–1275. https://doi.org/10.1136/bjsports-2018-099257

Jenkins, H.J., Downie, A.S., Moore, C.S., French, S.D. and Maher, C.G., 2021. Current evidence for spinal imaging in patients with low back pain: a systematic review of clinical practice guidelines. European Spine Journal, 30(3), pp.565–573. https://doi.org/10.1007/s00586-020-06671-6

Teunis, T., Lubberts, B., Reilly, B.T. and Ring, D., 2014. A systematic review and pooled analysis of the prevalence of rotator cuff disease with increasing age. Journal of Shoulder and Elbow Surgery, 23(12), pp.1913–1921. https://doi.org/10.1016/j.jse.2014.08.001