Why Don’t You Take X-rays During Your Exam?

This is a question we get frequently in the office.  There are situations where x-ray usage is necessary, but x-ray usage for exploration sake is not recommended under current best practice guidelines.

Here’s why…

What do X-rays show?

X-rays are best at identifying bony pathology.

This includes such processes as fractures, joint degeneration, bone cancers, or deformity.

You can also see inferences of soft tissues structures such as heart and lung shadows, gas bubbles in the intestines, and sometimes different types of tumors –  to name a few.

Forearm Fracture

What can’t be seen on X-rays?

Any type of soft tissues such as muscles, ligaments, tendons, nerves etc.

When is taking an x-ray useful?

It is proper clinical practice to only expose the patient with radiation if the outcome of the x-ray would change or guide the course of treatment.

This means that after a clinical history and exam has taken place, the practitioner believes there is reason for further investigation.

Examples include:

  • Ruling out a fracture (patient falls down the stairs and is having arm pain, but has not been to the ER).
  • Investigating possible red flags (ie. Cancer) that may be contributing to pain/condition.
  • Ruling out contraindications for treatment (some treatment options are unsafe in certain situations)

When not to take an X-ray?

An x-ray should not be taken for any of the following reasons:

Chest X-ray

  • To identify problems with soft tissues (muscle,ligaments, tendons) – MRI or Ultrasound are preferred in these situations.
  • For exploratory purposes (to check for spinal alignment, or to evaluate posture)
  • If there is a possibility the patient could be pregnant
  • To monitor how a patient is responding to treatment (ie. Before and after)
  • To evaluate acute pain (less than 6 weeks) without red flag indicators.

Because x-rays expose patients to radiation, unless there is a valid reason to have the x-ray, it is best to avoid it.

So why don’t we take x-rays during our chiropractic exams?

X-rays are harmful and should be avoided when not clinically indicated. Using x-rays as a justification for chiropractic treatment is problematic for many reasons. An X-ray is simply a photograph of your skeleton at a certain point in time.

There are many factors that influence how your body alignment will look in that photograph if used as justification for chiropractic care.

  • Were you in pain that day? Our body will lean a certain way to avoid a painful stimulus.
  • Were you given prompts to stand in a particular way? Having any outside influence while taking an x-ray, such as being told to “stand up straight” or even the absence of these instructions can influence how the bony alignment appears on film.
  • Were you standing, or laying down for the image? Weight bearing and non-weight bearing images will appear different.
  • Was the image taken at the beginning of the day or towards the end? Having an image taken after a long work day will look different than one taken first thing in the morning.
  • Can you be certain you were standing perfectly straight with your weight balanced equally on both legs? We never stand perfectly symmetrical; we often load or shift our weight from side to side as we adjust our standing posture.

These are all reasons that can influence how an x-ray looks or how it can be interpreted when using them to evaluate posture or alignment.

There is no reliability when using x-rays as a method or justification for ongoing chiropractic or manual therapy care. You can take an x-ray of the same person 30 seconds apart and have them look completely different.

Therefore, we simply do not use them as part of our screening process as the harm does not outweigh any perceived benefit.