There are arguments both for and against the use of X-rays as a part of chiropractic health care.

Many patients do not require X-rays; however, some chiropractors take them as a standard procedure, either as a defensive practice to rule out pathology (such as a possible tumor or fracture) and/or to aid in determining where to adjust the spine.

In most cases of non-traumatic musculoskeletal low back pain, an X-ray is not needed. One retrospective review found that in a sample of 350 X-rays, only 15% showed a significant pathology that changed treatment recommendations. For the other 85%, there were no clinically significant findings on the X-ray. The conclusion of this review and other similar reviews is that unless a thorough clinical evaluation specifically indicates the need for X-ray testing, it is not warranted and exposes the patient to unnecessary radiation.1 With that said, it may be reasonable to consider an x-ray after several weeks if there is an absence or plateau in symptom improvement.

Indications for X-rays in Chiropractic Health Care

As a general guideline, X-rays are recommended in the following cases:

  • If the patient has sustained a significant traumatic injury, as a bone may be broken or a joint may be dislocated
  • If an infection may be causing the patient's pain
  • If any significant disease is suspected, such as cancer or a possible tumor
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  • If any type of joint disease is suspected, such as arthritis causing joint pain
  • If the patient is over age 50 and has experienced any type of trauma (even a minor one)
  • For most patients over 65 years of age
  • Anyone who has been diagnosed with or who may be at risk for osteoporosis. The X-ray may be important to identify or rule out a possible vertebral fracture from osteoporosis.
  • Any suspected spinal instability
  • If the patient has had long-standing pain that has not responded to or resolved with previous health care treatment

As a general guideline, an X-ray is indicated if it is likely to inform the type of treatment recommended for the patient. In any of the above cases, an X-ray would likely provide critical information that will direct treatment protocols and/or referral options for the patient.

Contraindications for an X-ray

X-rays are not needed for most chiropractic patients. As a general rule an X-ray is not needed for chiropractic treatment of general musculoskeletal lower back pain in someone under age 65.

Specifically, an X-ray should not be performed for any of the following reasons:

  • To identify problems with soft tissues (muscles, tendons, or ligaments) or within the spinal disc itself. X-rays are only effective in identifying pathology with bones and joints, not with soft tissues. An MRI is usually needed to identify soft-tissue problems (for example, a disc pathology).
  • Purely for exploratory purposes. Most practitioners will have a good idea of the cause of the patient's pain before ordering the X-ray or other diagnostic test and will use the test to confirm their findings. Similarly, most chiropractors will have a good idea of the specific pathology they are trying to rule out with an X-ray.
  • If there is a possibility that the patient could be pregnant.

With most forms of general lower back pain, an X-ray will not be needed to guide the course of treatment. Because X-rays expose patients to radiation, unless there is a valid reason to have the X-ray, it is best to avoid it.


Questions about X-rays

Some questions that may be asked of the chiropractor include:

  • Does the chiropractor recommend an X-ray? If so, why?
    • Avoid chiropractors who insist on taking X-rays of every patient, regardless of what is wrong.
  • If an X-ray is taken by the chiropractor, how do the X-ray findings correlate to the patient's pain and symptoms?
    • It is common for an X-ray to show problems with the spine but the patient has no symptoms. If the patient does not have pain and the practitioner recommends continued chiropractic treatments based on the X-ray, it is advisable to get a second opinion from another chiropractor or medical professional. This same general rule is true for MRI scans or any other type of testing.
    • Avoid a chiropractor who compares a patient’s X-ray, most often "imperfect," to a "textbook perfect" spine as validation for extensive treatment, with promises that the patient's spine can be changed. The goal is not to have an anatomically perfect spine.
  • What other tests may be taken by the chiropractor?
    • If a practitioner is offering a high-tech test, patients may be well served to research the validity of the test before agreeing to it. Certain types of tests (surface EMG scan, for instance) may look impressive but in fact have little or no scientific data supporting their use and do not really help in making treatment decisions. Many tests commonly come with a high price tag that may not be covered by insurance.

The bottom line is that when used appropriately, X-rays can identify and/or rule out specific pathology and help guide appropriate treatment. However, they are not warranted in most cases for treatment of general back pain.


  1. Gatterman B. Guidelines in the Use of Radiography in Chiropractic. Dynamic Chiropractic. 1990;08(12). Accessed July 14, 2013.