95% of back pain is musculoskeletal, with no underlying medical causes of back pain. Usually these can be ruled out in the medical and examination, with Chiropractic and orthopaedic tests and most of the time scans and X-rays are not required. Sometimes, however, further tests are needed to clarify a diagnosis or rule out any more serious medical condition, or clarify the best course of treatment. Sometimes diagnostic imaging helps see into the body and prevents the need for exploratory surgery.


X-rays are used much less now in the diagnosis of back pain, and are commonly not recommended or even allowed to be taken unless there are clear signs that they are indicated with good medical reasons. Chiropractors used to take X-rays more routinely and some still do to show the structure of the spine and the extent and location of any wear and tear or degeneration, which can be helpful in pin-pointing the source of the underlying causes of back pain. medical profession takes the view that unless the patient is suffering, in pain, with a clear need for X-ray, then they are not generally necessary, often because osteoarthritis or wear and tear is almost universal and doesn’t really affect the treatment.

X-rays may well be indicated for:

  1. Severe trauma or possible fractures
  2. Hip osteoarthritis or wear and tear
  3. Bone tumours
  4. Osteoporosis (alongside bone density scans)
  5. Severe chronic long-term spinal pain that is not settling.
  6. Medical ‘Red-flags, possibly with night or deep bone pain
  7. Suspicion of other arthritic or joint diseases
  8. Spinal surgeons will now use X-rays alongside MRI scans to help build a full picture of a patient’s spine before considering surgery.

Referring for X-rays

If X-rays are required then you can be referred to a local hospital or X-ray department where they can be taken. The Chiropractor will need to submit a referral form with the clear medical reasons why they are required.

Obtaining X-rays and X-ray reports

If you have had X-rays taken at a hospital then I recommend asking for a copy of the X-rays and obtaining the X-ray report from the hospital or your GP surgery. You are legally entitled to these and they will help with the diagnosis when you attend for Chiropractic treatment.

X-ray picture and symptoms commonly don’t match

It’s very common that the X-ray picture and a patient’s symptoms don’t match. Sometimes the patient is in severe debilitating pain, yet their X-ray picture is ‘normal’ and at other times their X-rays may show severe wear and tear and leaving the practitioner to wonder how they are even able to stay active, yet the client is happily carrying on with life!

MRI scans

Magnetic resonance imaging (MRI) is a computer-generated image of bony structures and soft tissues such as muscles, ligaments, tendons, and blood vessels, all of which do not show on an X-ray. From a Chiropractic viewpoint it is most often helpful in determining whether there is disc involvement with a sciatic nerve pain.

Uses of MRI

  1. Disc herniation bulges, sciatic or nerve irritation
  2. Spinal stenosis, nerve entrapments in the spine
  3. Medical conditions like tumours, inflammation, infections, multiple sclerosis.

Ultrasound scans

MSK ultrasound for musculoskeletal conditions has made big advances and is now a firm part of the diagnostic toolkit for looking at various conditions. Ultrasound, often called ‘US’, is safe and painless, non-invasive, and does not use radiation. Using a probe or transducer on the skin with gel, it produces high frequency sound waves which travel into the body and rebound. These waves are computer captured to produce pictures of inside the body. Images are captured live, so can show movement inside the body and also show blood flowing through blood vessels.

Musculoskeletal uses of Ultrasound (US) include:

  1. Tendonitis and tendon tears in many areas of the body
  2. Shoulder rotator cuff muscles tendon tears
  3. Achilles tendon tears
  4. Ligament sprains or tears
  5. Inflammation or fluid in joints and bursae
  6. Early changes of rheumatoid arthritis
  7. Nerve entrapments such as carpal tunnel or ulnar nerve
  8. Soft tissue tumours, both benign and malignant
  9. Cysts, like ganglions
  10. Hernias
  11. Foreign bodies in the soft tissues or skin, like glass splinters
  12. Dislocations or fluid in the hips of young children
  13. Neck muscle abnormalities in infants, like torticollis
  14. Lumps & bumps or soft tissue injuries in children

Ultrasound-guided treatments

Ultrasound-guided treatments have become more and more common. They allow the practitioner to visualize the needle in real time as it enters the body and traverses to the desired location. This assures that the medication is accurately injected at the intended site. Ultrasound-guided injections are low cost and ease to perform in clinics, and improve the accuracy of injections from as low as 30-40% to 90-100%. They are commonly less painful with few complications and risks, and give real-time feedback, so the results can be seen. Ultrasound-guided treatments can be used to treat the following conditions:

  • Improve the accuracy of the injections to break calcific lumps in tendons
  • Corticosteroids injections
  • Hyaluronic acid or other therapies
  • Platelet Rich Plasma, Prolotherapy or Stem Cells
  • Useful for joint aspirations to rule out joint infection or gout

Common ultrasound-guided injections to the knee, hip or shoulder

Knee – Ultrasound can diagnose fluid in the knee, quadriceps and patellar tendons, extra-articular ligaments and some meniscus injuries.

Hip – Visualize the hip joint, bursa and surrounding muscles and tendons and inject with accuracy up to 96%.

Shoulder – Shows ultrasound to be as good as MRI in the diagnosis of rotator cuff tears. It Improves accuracy of injections to the Acromioclavicular (AC) joint, the Glenohumeral joint, the biceps tendon, and the subacromial bursa.

Other tools used in the diagnosis of back pain

Blood & urine tests for back pain

These are not often required in the diagnosis of back pain, but can be very useful in addition to other scans. They can be used for signs of inflammation, infection, cancer, and arthritis.

Bone Density (DEXA) Scans

A bone density (or DEXA) scan is a low dose X-ray to diagnose or assess your risk of osteoporosis or bone weakening. They are quick, painless and far more accurate than normal X-rays. An X-ray called Dual Energy X-ray Absorptiometry is passed through thebody. This is measured by computer. Bone density scans are very safe, with very low radiation levels, but nonetheless are not recommended for pregnant women.

When is a DEXA bone scan indicated?

  • In over 50s with a risk of developing osteoporosis
  • In under 50s with other risk factors, like smoking or a previous broken bone
  • Postmenopausal women are more at risk, with lower oestrogen decreasing bone density
  • Long-term use of steroids can also be a risk factor and lower bone density

Bone scans

Uses a small amount of a radioactive drug, a radiopharmaceutical, or temporary ‘dye’ injected into a vein that is absorbed by the bones, but released within 2-3 days. They show problems with bone metabolism, especially cancer spread to the bone i.e. prostate or breast.

Specifically, a bone scan is done to reveal problems with bone metabolism. Bone metabolism refers to the process in which bones break down and rebuild themselves. New bone formation is part of the healing process when bones are injured or broken. A bone scan is a good way to view and document abnormal metabolic activity in the bones. Results are abnormal if they show darker “hot spots” or lighter “cold spots” in the bones, areas of greater or lesser radioactivity. These can indicate a bone disorder, such as cancer or arthritis or infection in the bone. A bone scan is no greater risk than normal X-rays. The radioactive substance produces very little radiation exposure. The risk of having an allergic reaction to the tracers is low. Bone scans may be unsafe for pregnant or breastfeeding women.

The uses of bone scans include:

  • Arthritis
  • Avascular necrosis or dead bone tissue from lack of blood
  • Bone cancers
  • Metastatic or secondary cancer spread to the bone
  • Fibrous dysplasia
  • Fractures
  • Infection involving the bone
  • Paget’s disease, with weak deformed bones

Single-Photon Emission Computed Tomography (SPECT)

This is similar to a bone scan, but it creates deeper 3-D bone images. It is often used if a normal bone scan is inconclusive.


Discography involves injecting a contrast dye into a spinal disc thought to be causing low back pain. The fluid’s pressure in the disc will reproduce the person’s symptoms if the disc is the cause. The dye helps to show the damaged areas on CT (Computerised Tomography) scans taken following the injection.


Electrodiagnostics can identify problems related to the nerves in the back and legs or arms. Electromyography (EMG) is done by inserting fine needles in to muscles to test their electrical activity, weakness or responsiveness from the nerve supply.

Nerve conduction studies (NCS)

Two sets of electrodes are used to record the nerve’s electrical signals to a particular muscle to detect any nerve damage.

Evoked potential studies

One electrode is used to stimulate a sensory nerve, and a second on the scalp to records nerve signal transmission speed to the brain.

Computerised Tomography (CT)

Can show soft tissue structures that cannot be seen on conventional X-rays, such as disc rupture, spinal stenosis, or tumors.


They use a contrast dye injected in the spinal canal to enhance X-rays or CT scans. The dye shows spinal cord and nerve compression from herniated discs or fractures.