From the Guidelines
X-rays are performed in rheumatoid arthritis to assess joint damage, monitor disease progression, and guide treatment decisions. Initially, X-rays may appear normal in early disease but become valuable as the condition advances, revealing characteristic changes such as periarticular osteopenia (bone thinning around joints), joint space narrowing, bone erosions, and joint deformities. These radiographic findings help differentiate rheumatoid arthritis from other inflammatory arthritides and degenerative joint diseases.
- X-rays are typically ordered at diagnosis to establish a baseline and then periodically (usually annually) to track structural changes over time.
- They are particularly useful for examining commonly affected areas like hands, wrists, and feet.
- While more advanced imaging techniques like ultrasound and MRI can detect earlier inflammatory changes, X-rays remain essential due to their accessibility, lower cost, and ability to visualize bone damage. The progression of radiographic damage correlates with functional disability, making X-rays an important tool for assessing treatment effectiveness and potentially adjusting therapy if joint destruction continues despite clinical improvement, as recommended by the American College of Radiology 1.
According to the EULAR recommendations for the use of imaging of the joints in the clinical management of rheumatoid arthritis, conventional radiography (CR) of the hands and feet should be used as the initial imaging technique to detect damage 1.
- The presence of inflammation seen with ultrasound or MRI can be used to predict the progression to clinical RA from undifferentiated inflammatory arthritis.
- MRI bone oedema is a strong independent predictor of subsequent radiographic progression in early RA and should be considered for use as a prognostic indicator.
- Joint inflammation (synovitis) detected by MRI or ultrasound as well as joint damage detected by CR, MRI or ultrasound can also be considered for the prediction of further joint damage.
In clinical practice, the use of imaging tools in rheumatoid arthritis is still evolving, and further research is needed to optimize their use, particularly in terms of which joints to image and the feasibility, costs, and training required for ultrasound and MRI 1.
From the Research
Reasons for Using X-rays in Rheumatoid Arthritis
- X-rays are used to assess the degree of joint damage in rheumatoid arthritis (RA) patients, which is a key outcome in RA 2
- Radiographic imaging provides a permanent record of joint pathology, allowing for serial evaluation and objective scoring of joint damage 2, 3
- X-rays can detect radiographic erosions, which are a characteristic sign of RA, and can be used to monitor disease progression 3, 4
- Radiographic findings can be used to evaluate the effectiveness of treatment and to predict severe outcomes of RA, including costs and mortality 3
Advantages of X-rays in Rheumatoid Arthritis
- X-rays are easily available, inexpensive, and relatively safe 4
- They provide immediate information and can be interpreted easily by rheumatologists 4
- Radiographic data are reproducible and can be used for serial evaluation and follow-up 4
- X-rays can detect subtle changes occurring at the bone level, making them a valuable tool for RA screening 4
Limitations of X-rays in Rheumatoid Arthritis
- X-rays may not provide good information on early RA changes, such as synovial inflammation or other soft-tissue structural changes 4, 5
- Other imaging modalities, such as magnetic resonance imaging (MRI) and ultrasonography, may be more sensitive than radiography in detecting abnormalities 3, 5
- Treatment of RA should be initiated before evidence of damage, and functional measures are more significant than radiographic findings in predicting severe outcomes of RA 3