Content and consistency of clinical guidelines for diagnostic imaging of non-traumatic lower back, knee and shoulder pain: a scoping review


For many patients with musculoskeletal (MSK) pain such as low back (LBP), knee and shoulder pain, there is clinical uncertainty about the role of diagnostic imaging. Given the aging population and the prevalence of structural changes in those with and without pain, the relevance of scan findings is often questionable. Despite this, the use of diagnostic imaging is increasing, and patients often perceive imaging results to be authoritative. Clinical practice guidelines (CPGs) have been developed to improve clinical decision-making and there are many available CPGs relevant to DI in patients with non-traumatic MSK pain. The aim of this study was to summarise the content and understand the consistency of recommendations within recent CPGs relevant for adults with non-traumatic MSK pain conditions such as LBP, knee and shoulder.

The routine use of DI is discouraged....
The use of DI is encouraged where serious pathology is suspected.


A scoping review of CPGs developed and published between April 2009 and April 2019 was conducted. A search of electronic databases (Medline, CINAHL, PsychInfo, SportDiscus) was undertaken alongside a search of guideline repositories. This was supplemented through searching the websites of relevant professional bodies, circulating a request for CPGs from these professional bodies, a Google snowball search and the use of Twitter. CPGs were included if they were relevant to UK practice, including those that had been developed for international use.


Results: 31 CPGs were included, 16 of which focused on a specific MSK presentation: LBP (n=5), knee (n=8), shoulder pain (n=3). 15 of these focused on a regional condition that has the potential to present as LBP, knee or shoulder pain (n = 15). 19 of the included CPGs were developed in the UK, 9 were developed by European groups and three were developed by International groups. The use of Twitter retrieved eight additional citations that were not otherwise identified; two were included within the final 31. Similarities between CPGs:

· The routine use of DI is discouraged

· The use of DI is encouraged where serious pathology is suspected

· The use of DI can be considered when the person is not responding to initial conservative management and the result is expected to change management

Differences between CPGs:

· The use of x-ray in those with LBP is discouraged unless there is a suspicion of a specific pathology, whilst in those with knee or shoulder pain, an x-ray is encouraged as the initial investigation

The recommendations are sometimes written with the care setting in mind e.g. primary care; whilst others are written with the level of expertise in mind e.g. specialist setting which have implications for future CPG development

Conclusion(s): CPGs demonstrated consistency regarding DI being discouraged unless expected to change management. This represents the most comprehensive review of CPGs and recommendations for use of DI. Future qualitative work should look to better understand the reasons for requesting DI from the perspective of referring clinicians and patients.

Cost and savings

Not applicable. 


With new clinical delivery models such as FCP being implemented, there is an urgent need to understand appropriate use of DI to support both clinicians in these roles and patients seeking care, to harness efficiencies and improve patient outcomes.

Top three learning points

1 - The routine use of imaging is discouraged.

2 - The use of imaging is encouraged where serious pathology is suspected.

3 - The use of imaging an be considered when the person is not responding to initial conservative management and the result is expected to change management.

Funding acknowledgements

This work was funded via an ACORN PhD Studentship from Keele University.