X-rays can help diagnose rheumatoid arthritis by showing changes in your bones and joints. They are often used along with other imaging tests, such as MRIs or ultrasounds.

Rheumatoid arthritis (RA) is an autoimmune condition that can cause pain and swelling in your joints and contribute to joint damage throughout your body.

While there are times when you might have not have symptoms, you might experience pain, stiffness, or swelling in some or many of your joints, particularly in your hands and feet. You might also have a fever or experience weakness.

Healthcare professionals use a combination of tools to diagnose RA, including blood tests and medical imaging that may include X-rays. This article explains how RA can show up on X-rays and what to discuss with your healthcare team.

Healthcare professionals diagnose RA with a combination of assessments, including:

  • medical history
  • physical exam
  • lab testing
  • X-rays (though it may be difficult to see early stage RA on X-rays)

In the early stages, RA causes soft tissue inflammation that may not appear on an X-ray. Bone damage and abnormalities develop later and are easier to see. You may also notice gaps between the joints or bones of your hands or feet on X-rays or spots or lesions on your bones.

Although X-rays alone may not be the best first choice for early diagnosis and treatment, they can be helpful for identifying a baseline for your condition. Doctors can refer to early X-rays when examining the progression of your condition.

Musculoskeletal ultrasounds and MRIs can help diagnose RA earlier. Ultrasounds and MRIs are noninvasive ways to look at all of your joints at once.

The American College of Rheumatology recommends using ultrasounds or MRIs in combination with X-rays, as they are better at identifying inflammation than a physical exam or X-ray alone.

A 2020 research review found that ultrasound may help people with unspecified arthritis get a proper diagnosis and begin treatment early. In addition, a 2022 research review found that ultrasound may be especially helpful in identifying RA inflammation and people at higher risk of disease relapse.

Rheumatology offices often have ultrasound machines on site. Getting an ultrasound is usually less expensive than undergoing an MRI, although it might be more expensive than an X-ray. MRIs have pros and cons when compared with X-rays, including cost.

Positron emission tomography (PET) scans, typically used to diagnose cancer, also showed promise in diagnosing RA in a 2018 mice study. However, PET scans are not often recommended by healthcare professionals because they are more expensive and insurance coverage may not be possible.

Your healthcare team may order X-rays of your hands, an area where RA most commonly presents.

When a healthcare professional examines your X-rays, they look for the following:

  • changes in the shapes of your joints
  • lesions or damage to your bones
  • cartilage loss
  • misalignment (called subluxation)
  • soft tissue swelling and calcification
  • bone density loss
  • cysts

According to research from 2016, one of the earliest signs of RA is joint space widening. The spaces between your joints can change in size depending on how much fluid is between them. You may have extra fluid between your joints at different times in RA.

Some osteopenia, or bone loss, may appear earlier than other signs. Bone erosion may also show up on an X-ray, although it usually develops as RA progresses.

The research from 2016 suggests that an X-ray might be helpful for diagnosis and establishing a baseline, but an ultrasound or MRI is more useful for monitoring the condition.

The researchers concluded that because people with RA tend to have many follow-up appointments, X-rays may expose them to unnecessary radiation. They found that ultrasounds and MRIs didn’t have the same risk of radiation exposure and were more likely to identify other features of RA, such as fluid and soft tissue changes.

Talk with your doctor about which imaging tests are best for you. If you already received an RA diagnosis, talk with doctors about whether an ultrasound, MRI, X-ray, or a combination of these tests would help get a better picture of your condition’s progression.

X-rays can help diagnose rheumatoid arthritis. They are most effective when combined with other tests, such as physical exams and ultrasounds.

Some of the earliest RA signs on X-rays include changes in the size of the spaces between your joints, bone loss, or bone or joint misalignment. X-rays can establish a baseline for your condition, but your healthcare team may also use ultrasounds, MRIs, or other tests to help monitor it.