When should I get an X-ray after a fall?

You should get an X-ray after a fall when you cannot bear weight on the limb, when there is visible deformity, when the pain is severe and persistent, or when there is rapid swelling. Minor sprains often do not need imaging if you can walk and the pain improves over a few days.

How long should I wait before getting an MRI for back pain?

You should wait at least 4 to 6 weeks before getting an MRI for typical back pain, unless red-flag symptoms appear. Most back pain resolves with gentle movement, anti-inflammatories, and physical therapy in that window. Imaging earlier rarely changes the outcome.

What is the difference between a sprain and a strain?

The difference between a sprain and a strain is the tissue injured. A sprain is a stretch or tear of a ligament, the band that connects bone to bone. A strain is a stretch or tear of a muscle or tendon. Both heal with relative rest, gradual movement, and sometimes physical therapy.

Can ultrasound replace MRI for shoulder pain?

Ultrasound can replace MRI for many shoulder problems, particularly rotator cuff tears, bursitis, and tendinopathy. The advantage is that we can move the shoulder during the scan and see what happens. MRI is still better for labral tears and bone marrow problems.

What is a DEXA scan and when do I need one?

A DEXA scan measures bone mineral density and is used to diagnose osteopenia and osteoporosis. Most women should get one at age 65, men at 70, or earlier if there are risk factors like early menopause, steroid use, low body weight, or family history of fractures.

How do I prepare for a DEXA scan?

Skip calcium supplements for the 24 hours before your DEXA scan. Undissolved calcium tablets in your gut can sit in the scanner's field of view and falsely inflate the density reading. Wear clothing without metal zippers or buttons, and tell the technologist about any recent barium studies or contrast scans, which can also interfere.

Do I need contrast for a joint MRI?

You usually do not need contrast for a joint MRI for routine evaluation. Contrast (gadolinium) may be added when looking for very subtle labral tears or post-surgical changes. The radiologist or referring physician will specify "with" or "without" contrast on the order. Some facilities ask you to fast for 2 to 4 hours before a contrast MRI, so check the prep instructions when you book.

How accurate is an X-ray for stress fractures?

X-rays are not very accurate for stress fractures in the first 2 to 3 weeks. Many stress fractures are invisible until the bone starts to heal. If a stress fracture is suspected and the X-ray is negative, MRI is the next step because it shows bone marrow edema right away.

Will my insurance cover bone and joint imaging?

Insurance usually covers bone and joint imaging when there is a clear clinical reason like trauma, persistent pain, or abnormal exam findings. MRI typically requires prior authorization, which our team handles. X-ray and ultrasound rarely need a prior auth.

Why do MRIs in older adults often show "degenerative changes" that are not the cause of pain?

MRIs in older adults often show degenerative changes that are not the cause of pain because aging spines and joints accumulate normal wear over decades. Studies show that more than 50% of pain-free 40-year-olds have disc bulges on MRI. The picture rarely matches the pain.

What is the difference between a meniscus tear and a ligament tear on MRI?

The difference between a meniscus tear and a ligament tear on MRI is location and signal. The meniscus is a C-shaped cartilage cushion in the knee, and tears appear as bright lines through it. Ligaments like the ACL or MCL appear as thick dark bands, and tears show up as discontinuity or bright signal within the band.

When is musculoskeletal ultrasound better than MRI?

Musculoskeletal ultrasound is better than MRI when we need to watch a joint move, guide an injection, or evaluate a tendon in real time. It is also faster and cheaper. The trade-off is that ultrasound cannot see deep structures like the hip joint surface or spine.

What is a bone scan and when is it ordered?

A bone scan is a nuclear medicine test that uses a radioactive tracer to highlight areas of high bone turnover, like fractures, infections, or metastases. It is ordered when we suspect a stress fracture missed on X-ray, evaluate cancer spread, or work up unexplained bone pain.

How does cartilage show up on MRI?

Cartilage shows up on MRI as a thin layer covering the bone surfaces. Healthy cartilage looks smooth and uniform. Damaged cartilage looks thinned, irregular, or has bright fluid signal where the surface is worn through. Specialized sequences like T2 mapping can quantify early cartilage breakdown.

What is the role of weight-bearing X-rays in knee or hip pain?

The role of weight-bearing X-rays in knee or hip pain is to show how the joint behaves under load. Standing X-rays reveal joint space narrowing and alignment issues that lying-down X-rays miss. They are essential before any major orthopedic decision.

How does platelet-rich plasma (PRP) imaging guidance work?

Platelet-rich plasma (PRP) imaging guidance uses ultrasound in real time to guide the injection into the injured tendon or joint. Without imaging, "blind" injections frequently miss the target. We always recommend image-guided injections for high-stakes procedures.

What is the radiation dose of a CT scan for a fracture?

The radiation dose of a CT scan for a fracture varies by location. A CT of the wrist is about 0.1 mSv. A CT of the spine or pelvis can be 6 to 8 mSv. We weigh the diagnostic benefit against the cumulative radiation, particularly in younger patients.

Why is MRI preferred for spinal cord evaluation?

MRI is preferred for spinal cord evaluation because it shows the cord, nerves, discs, and surrounding tissue all at once. CT shows bone well but cannot reliably see soft cord injury, multiple sclerosis lesions, or early infection.

How does a contrast MRI of the spine differ from a non-contrast MRI?

A contrast MRI of the spine differs from a non-contrast MRI by adding gadolinium, which highlights inflammation, infection, tumors, and post-surgical scar tissue. Routine disc evaluation does not need contrast. Workup of suspected infection, cancer, or recurrent disc herniation does.

What is dynamic ultrasound and how does Fishtown Medicine use it?

Dynamic ultrasound is real-time ultrasound that watches a joint or tendon move. Fishtown Medicine works with imaging partners who use it to evaluate snapping hip syndrome, peroneal tendon dislocation, and ulnar nerve subluxation, all conditions that look normal at rest.

How do we know if surgery is needed for a torn ligament?

We know if surgery is needed for a torn ligament based on the type of tear, the patients activity level, and the response to conservative care. A complete ACL tear in a competitive athlete usually warrants surgery. A partial tear in a sedentary patient often heals with rehab. The MRI alone does not decide.

When should I get an X-ray after a fall?

You should get an X-ray after a fall when you cannot bear weight on the limb, when there is visible deformity, when the pain is severe and persistent, or when there is rapid swelling. Minor sprains often do not need imaging if you can walk and the pain improves over a few days.

How long should I wait before getting an MRI for back pain?

You should wait at least 4 to 6 weeks before getting an MRI for typical back pain, unless red-flag symptoms appear. Most back pain resolves with gentle movement, anti-inflammatories, and physical therapy in that window. Imaging earlier rarely changes the outcome.

What is the difference between a sprain and a strain?

The difference between a sprain and a strain is the tissue injured. A sprain is a stretch or tear of a ligament, the band that connects bone to bone. A strain is a stretch or tear of a muscle or tendon. Both heal with relative rest, gradual movement, and sometimes physical therapy.

Can ultrasound replace MRI for shoulder pain?

Ultrasound can replace MRI for many shoulder problems, particularly rotator cuff tears, bursitis, and tendinopathy. The advantage is that we can move the shoulder during the scan and see what happens. MRI is still better for labral tears and bone marrow problems.

What is a DEXA scan and when do I need one?

A DEXA scan measures bone mineral density and is used to diagnose osteopenia and osteoporosis. Most women should get one at age 65, men at 70, or earlier if there are risk factors like early menopause, steroid use, low body weight, or family history of fractures.

How do I prepare for a DEXA scan?

Skip calcium supplements for the 24 hours before your DEXA scan. Undissolved calcium tablets in your gut can sit in the scanner's field of view and falsely inflate the density reading. Wear clothing without metal zippers or buttons, and tell the technologist about any recent barium studies or contrast scans, which can also interfere.

Do I need contrast for a joint MRI?

You usually do not need contrast for a joint MRI for routine evaluation. Contrast (gadolinium) may be added when looking for very subtle labral tears or post-surgical changes. The radiologist or referring physician will specify "with" or "without" contrast on the order. Some facilities ask you to fast for 2 to 4 hours before a contrast MRI, so check the prep instructions when you book.

How accurate is an X-ray for stress fractures?

X-rays are not very accurate for stress fractures in the first 2 to 3 weeks. Many stress fractures are invisible until the bone starts to heal. If a stress fracture is suspected and the X-ray is negative, MRI is the next step because it shows bone marrow edema right away.

Will my insurance cover bone and joint imaging?

Insurance usually covers bone and joint imaging when there is a clear clinical reason like trauma, persistent pain, or abnormal exam findings. MRI typically requires prior authorization, which our team handles. X-ray and ultrasound rarely need a prior auth.

Why do MRIs in older adults often show "degenerative changes" that are not the cause of pain?

MRIs in older adults often show degenerative changes that are not the cause of pain because aging spines and joints accumulate normal wear over decades. Studies show that more than 50% of pain-free 40-year-olds have disc bulges on MRI. The picture rarely matches the pain.

What is the difference between a meniscus tear and a ligament tear on MRI?

The difference between a meniscus tear and a ligament tear on MRI is location and signal. The meniscus is a C-shaped cartilage cushion in the knee, and tears appear as bright lines through it. Ligaments like the ACL or MCL appear as thick dark bands, and tears show up as discontinuity or bright signal within the band.

When is musculoskeletal ultrasound better than MRI?

Musculoskeletal ultrasound is better than MRI when we need to watch a joint move, guide an injection, or evaluate a tendon in real time. It is also faster and cheaper. The trade-off is that ultrasound cannot see deep structures like the hip joint surface or spine.

What is a bone scan and when is it ordered?

A bone scan is a nuclear medicine test that uses a radioactive tracer to highlight areas of high bone turnover, like fractures, infections, or metastases. It is ordered when we suspect a stress fracture missed on X-ray, evaluate cancer spread, or work up unexplained bone pain.

How does cartilage show up on MRI?

Cartilage shows up on MRI as a thin layer covering the bone surfaces. Healthy cartilage looks smooth and uniform. Damaged cartilage looks thinned, irregular, or has bright fluid signal where the surface is worn through. Specialized sequences like T2 mapping can quantify early cartilage breakdown.

What is the role of weight-bearing X-rays in knee or hip pain?

The role of weight-bearing X-rays in knee or hip pain is to show how the joint behaves under load. Standing X-rays reveal joint space narrowing and alignment issues that lying-down X-rays miss. They are essential before any major orthopedic decision.

How does platelet-rich plasma (PRP) imaging guidance work?

Platelet-rich plasma (PRP) imaging guidance uses ultrasound in real time to guide the injection into the injured tendon or joint. Without imaging, "blind" injections frequently miss the target. We always recommend image-guided injections for high-stakes procedures.

What is the radiation dose of a CT scan for a fracture?

The radiation dose of a CT scan for a fracture varies by location. A CT of the wrist is about 0.1 mSv. A CT of the spine or pelvis can be 6 to 8 mSv. We weigh the diagnostic benefit against the cumulative radiation, particularly in younger patients.

Why is MRI preferred for spinal cord evaluation?

MRI is preferred for spinal cord evaluation because it shows the cord, nerves, discs, and surrounding tissue all at once. CT shows bone well but cannot reliably see soft cord injury, multiple sclerosis lesions, or early infection.

How does a contrast MRI of the spine differ from a non-contrast MRI?

A contrast MRI of the spine differs from a non-contrast MRI by adding gadolinium, which highlights inflammation, infection, tumors, and post-surgical scar tissue. Routine disc evaluation does not need contrast. Workup of suspected infection, cancer, or recurrent disc herniation does.

What is dynamic ultrasound and how does Fishtown Medicine use it?

Dynamic ultrasound is real-time ultrasound that watches a joint or tendon move. Fishtown Medicine works with imaging partners who use it to evaluate snapping hip syndrome, peroneal tendon dislocation, and ulnar nerve subluxation, all conditions that look normal at rest.

How do we know if surgery is needed for a torn ligament?

We know if surgery is needed for a torn ligament based on the type of tear, the patients activity level, and the response to conservative care. A complete ACL tear in a competitive athlete usually warrants surgery. A partial tear in a sedentary patient often heals with rehab. The MRI alone does not decide.

Bone and Joint Imaging 101 | Fishtown Medicine

TL;DR30-second take

Bone and joint imaging includes X-ray for fractures and arthritis, musculoskeletal ultrasound for tendons and ligaments, and MRI for soft tissue injuries like discs and ACL tears. We start simple and only move to MRI when the answer changes the treatment plan, particularly since most back pain resolves without imaging.

Whether it is a "crack" in the ankle on the El station stairs or a dull ache in the lower back from desk work, choosing the right imaging tool is the first step to recovery. At Fishtown Medicine, we balance the speed of X-rays with the deep-tissue detail of MRIs to keep your performance and longevity on track.

Bad imaging decisions can put healthy people on the sidelines for months. Good imaging decisions answer one question and clear the path back to movement.

What is the first-line evaluation for bone and joint pain?

The first-line evaluation for bone and joint pain usually starts with the simplest tool that can answer the clinical question. We rule out major structural problems before ordering anything fancy.

X-rays: Fast and low-radiation, X-rays catch fractures, dislocations, and severe arthritis. Easily available at any local Philadelphia imaging center.
Musculoskeletal ultrasound: Perfect for moving tissues like shoulders and knees. We use it to look at tendons, ligaments, and fluid in real time, and we can guide injections with it too.

When do we move to advanced imaging?

We move to advanced imaging when first-line tools cannot answer the clinical question. The two main advanced options are:

MRI: The gold standard for soft tissue. If we suspect a labral tear, herniated disc, or ACL injury, an MRI is the right call. No radiation, but the scan takes 30 to 60 minutes.
CT scan (bone-specific): Used for complex fractures where we need a 3D view of bone with high precision, particularly around the spine, pelvis, or wrist.

Why is "wait and see" the right rule for back pain?

"Wait and see" is the right rule for most back pain because early MRIs often lead to worse outcomes, not better ones. Here is why:

Most back pain is muscular or fascial and resolves with nervous system regulation and gentle movement within 4 to 6 weeks.
MRIs in healthy 40-year-olds frequently show "degenerative changes" that have been there for years and are not the source of the current pain.
Patients who get early MRIs are more likely to receive injections, surgery, and disability claims, even when the imaging findings are unrelated to their symptoms.

We hold off on imaging unless there are specific red flags. The flags are listed below.

What are the bone and joint imaging options compared?

Bone and joint imaging options compared:

Tool	Best For	Pros	Cons
X-Ray	Fractures, arthritis.	Lowest cost, fast.	Cannot see soft tissue.
Ultrasound	Tendons, rotator cuff.	Dynamic, can move the joint.	Operator-dependent.
MRI	Ligaments, spine, discs.	Extreme detail.	Highest cost; no metal.
CT Bone	Complex fractures.	3D structural detail.	Uses radiation.
DEXA	Bone density.	Gold standard for osteoporosis.	Limited to bone density.

Fishtown Medicine

A 90-minute conversation with Dr. Ash. A written plan you can actually follow.

Start your intake

Guidance from the clinic

"Treat the patient, not the picture. I see many people with perfectly normal MRIs who are in intense pain, and people with terrible-looking MRIs who run marathons. My goal is to use imaging to confirm a clinical suspicion, not to find reasons to put you on the sidelines. We use the data to build a roadmap back to movement, not away from it."

Red Flags: When Imaging Cannot Wait

Seek immediate evaluation if your bone or joint pain includes:

Sudden incontinence: Any loss of bowel or bladder control with back pain is a neurological emergency.
Saddle numbness: Loss of sensation in the groin or inner thighs.
Night pain: Intense pain that wakes you and does not change with position.
Trauma plus deformity: A limb that looks visibly out of place or cannot bear any weight.
Fever plus joint swelling: Suggests a possible joint infection (septic arthritis).

Key Takeaways

X-rays find broken bones; MRIs find torn tissues.
Most back pain resolves without imaging in 4 to 6 weeks.
Musculoskeletal ultrasound is a high-leverage tool for sports injuries.
Clinical assessment matters more than the picture.

Scientific References

Brinjikji W, et al. "Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations." American Journal of Neuroradiology. 2015.
Chou R, et al. "Imaging strategies for low-back pain: systematic review and meta-analysis." The Lancet. 2009.
Smith J, et al. "Diagnostic ultrasound of the shoulder: a state-of-the-art review." PM&R. 2015.
Cosman F, et al. "Clinician's Guide to Prevention and Treatment of Osteoporosis." Osteoporosis International. 2014.

Dr. Ash is a board-certified internal medicine physician specializing in preventive medicine and healthspan optimization at Fishtown Medicine in Philadelphia.

Fishtown Medicine | Diagnostics

2418 E York St, Philadelphia, PA 19125(267) 360-7927 hello@fishtownmedicine.comHSA/FSA Eligible

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Frequently Asked Questions

Common Questions

Deep-Dive Questions

Ready when you are

Start your intake

Dr. Ash reads every intake himself, and answers questions personally - usually within a few hours.

TL;DR30-second take

Bad imaging decisions can put healthy people on the sidelines for months. Good imaging decisions answer one question and clear the path back to movement.

What is the first-line evaluation for bone and joint pain?

The first-line evaluation for bone and joint pain usually starts with the simplest tool that can answer the clinical question. We rule out major structural problems before ordering anything fancy.

X-rays: Fast and low-radiation, X-rays catch fractures, dislocations, and severe arthritis. Easily available at any local Philadelphia imaging center.
Musculoskeletal ultrasound: Perfect for moving tissues like shoulders and knees. We use it to look at tendons, ligaments, and fluid in real time, and we can guide injections with it too.

When do we move to advanced imaging?

We move to advanced imaging when first-line tools cannot answer the clinical question. The two main advanced options are:

MRI: The gold standard for soft tissue. If we suspect a labral tear, herniated disc, or ACL injury, an MRI is the right call. No radiation, but the scan takes 30 to 60 minutes.
CT scan (bone-specific): Used for complex fractures where we need a 3D view of bone with high precision, particularly around the spine, pelvis, or wrist.

Why is "wait and see" the right rule for back pain?

"Wait and see" is the right rule for most back pain because early MRIs often lead to worse outcomes, not better ones. Here is why:

Most back pain is muscular or fascial and resolves with nervous system regulation and gentle movement within 4 to 6 weeks.
MRIs in healthy 40-year-olds frequently show "degenerative changes" that have been there for years and are not the source of the current pain.
Patients who get early MRIs are more likely to receive injections, surgery, and disability claims, even when the imaging findings are unrelated to their symptoms.

We hold off on imaging unless there are specific red flags. The flags are listed below.

What are the bone and joint imaging options compared?

Bone and joint imaging options compared:

Tool	Best For	Pros	Cons
X-Ray	Fractures, arthritis.	Lowest cost, fast.	Cannot see soft tissue.
Ultrasound	Tendons, rotator cuff.	Dynamic, can move the joint.	Operator-dependent.
MRI	Ligaments, spine, discs.	Extreme detail.	Highest cost; no metal.
CT Bone	Complex fractures.	3D structural detail.	Uses radiation.
DEXA	Bone density.	Gold standard for osteoporosis.	Limited to bone density.

Fishtown Medicine

A 90-minute conversation with Dr. Ash. A written plan you can actually follow.

Start your intake

Guidance from the clinic

Red Flags: When Imaging Cannot Wait

Seek immediate evaluation if your bone or joint pain includes:

Sudden incontinence: Any loss of bowel or bladder control with back pain is a neurological emergency.
Saddle numbness: Loss of sensation in the groin or inner thighs.
Night pain: Intense pain that wakes you and does not change with position.
Trauma plus deformity: A limb that looks visibly out of place or cannot bear any weight.
Fever plus joint swelling: Suggests a possible joint infection (septic arthritis).

Key Takeaways

X-rays find broken bones; MRIs find torn tissues.
Most back pain resolves without imaging in 4 to 6 weeks.
Musculoskeletal ultrasound is a high-leverage tool for sports injuries.
Clinical assessment matters more than the picture.

Scientific References

Brinjikji W, et al. "Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations." American Journal of Neuroradiology. 2015.
Chou R, et al. "Imaging strategies for low-back pain: systematic review and meta-analysis." The Lancet. 2009.
Smith J, et al. "Diagnostic ultrasound of the shoulder: a state-of-the-art review." PM&R. 2015.
Cosman F, et al. "Clinician's Guide to Prevention and Treatment of Osteoporosis." Osteoporosis International. 2014.

Dr. Ash is a board-certified internal medicine physician specializing in preventive medicine and healthspan optimization at Fishtown Medicine in Philadelphia.