Written by: LSRI Editorial Team
Medically reviewed by Dr Prashant Sankaye, Consultant MSK Radiologist ·
Last Updated: October 14, 2026
Read Time: 21 Minutes
Written by the LSRI clinical team and medically reviewed by Dr Prashant Sankaye, Consultant MSK Radiologist, on 9 October 2026.
Treatment can only be as good as the diagnosis it is aimed at. When a problem with the bones, joints, muscles, tendons or spine (a musculoskeletal, or MSK, problem) is diagnosed late or labelled wrongly, people can spend months on treatment aimed at the wrong thing. A small number of these conditions can cause permanent harm within hours or days.
This guide introduces our series on early diagnosis: what the research says about delay, which conditions cannot wait, what early imaging can and cannot show, and why most aches and pains do not need a scan at all.
Key points
- Diagnostic error is common: one US estimate is about 1 in 20 adults in outpatient care each year, and most people will experience at least one in their lifetime1,2.
- In one UK emergency department, 4 in 5 recorded diagnostic errors were missed fractures3, and in another study the commonest reason a fracture was missed on the first X-ray report was that the break was subtle4.
- A few conditions, such as cauda equina syndrome, septic arthritis and spinal infection, can cause lasting harm within hours to days; others, such as inflammatory arthritis, cause damage over months5,6,7,8.
- Most back pain is not serious: in one study of 1,172 people with new low back pain in primary care, fewer than 1 in 100 had a serious cause9.
- Scans often show changes in people with no pain, so imaging works best when used selectively and read alongside your symptoms10,11,12.
Why does early, accurate diagnosis matter?
Because the right treatment depends on the right diagnosis. A late or wrong diagnosis can mean the right treatment starts too late, or the wrong treatment carries on for too long.
A 2015 report from the US National Academies of Sciences, Engineering, and Medicine defined diagnostic error as a failure to establish an accurate and timely explanation of a patient’s health problem, or to explain it to the patient2. It concluded that most people will experience at least one diagnostic error in their lifetime2.
A US study that combined three large studies estimated that about 5% of adults seen in outpatient care, around 12 million people a year, experience a diagnostic error, and that about half of these errors could potentially cause harm1. A 2024 US analysis estimated that about 795,000 Americans a year die or are permanently disabled because of harm from misdiagnosis of dangerous conditions, with a plausible range of about 600,000 to 1 million7. These are US estimates and may not apply directly to other countries.
In MSK medicine the cost of delay can be quieter: weeks of exercises on a fracture that needs protecting, or years of back pain before inflammatory arthritis is recognised. Different problems need different treatment, from rehabilitation to an injection, surgery or emergency care. Hence our approach: diagnose first, diagnose accurately, then treat.
How often are bone and joint problems missed?
Missed fractures are a common kind of diagnostic error in emergency departments. Over four years in one UK hospital emergency department, 953 diagnostic errors were recorded in 934 patients, and 79.7% of the errors were missed fractures3. The commonest reasons for error were an X-ray that was misread (77.8% of errors) or not taken (13.4%)3.
In another emergency department study of 3,081 limb fractures, 3.7% were missed in the first X-ray reports, and the most common reason was that the fracture was subtle4. Some fractures cannot be seen on X-ray at all: across 35 studies of older people with suspected hip fracture and no definite fracture on X-ray, further imaging (with MRI as the reference test) found a fracture needing surgery in 39%13.
These problems can be missed for system and biological reasons:
- Early symptoms are often vague, and serious conditions can feel like common, harmless ones.
- Early X-rays can be normal, because some fractures do not show on X-ray13, and X-rays are poor at showing problems in the bone marrow and soft tissues. In one audit of cancer pressing on the spinal cord, plain X-rays predicted the level of compression in only 21% of people14.
- Warning signs are common in people without a serious cause. In the primary care study above, 80% of people with back pain had at least one “red flag” (warning sign), yet fewer than 1 in 100 had a serious cause, so the rare serious case is hard to spot9.
How quickly can delay cause harm?
It depends on the condition. A few are emergencies where hours count, some need a diagnosis within days to weeks, and others cause damage slowly over months or years.
Go to A&E or call 999 now (in the UK) if you have back pain and:
- numbness, tingling or weakness in both legs
- loss of feeling around your genitals or anus
- new problems with your bladder or bowels, such as difficulty peeing or wetting or soiling yourself
- loss of sexual sensation or function
- chest pain
- pain that started after a serious accident
Also go to A&E or call 999 now for severe hip pain after a fall or injury, or if you cannot walk or put weight on your leg15. Go to A&E the same day for a suddenly hot, swollen, very painful joint, especially with a fever, or for back pain with a fever or shivers. LSRI is not an emergency service. Outside the UK, call your local emergency number: 112 in the EU, 911 in the US and Canada, 000 in Australia.
Hours: emergencies
| Condition | Warning signs | What the research shows | Read more |
|---|---|---|---|
| Cauda equina syndrome (pressure on the nerves at the base of the spine) | Numbness around the genitals or anus, new bladder or bowel problems, symptoms in both legs16 | Whether surgery within a fixed time, such as 48 hours, gives better results is debated, and the studies are mostly observational. A 2026 review of 15 studies found that long-term results depended most on bladder function before surgery5, which is why these warning signs need A&E or 999 straight away16. | Cauda equina syndrome warning signs |
| Septic arthritis (infection inside a joint) | A suddenly painful, hot, swollen joint that is hard to move, often with a fever6 | In a UK study of hospital patients from 1982 to 1991, 11.5% died and a further 31.6% had complications such as bone infection or recorded loss of joint function17. | The hot, swollen joint |
| Spinal cord compression from cancer | Severe back pain, or pain spreading around the chest or down a limb, in someone with cancer now or in the past14 | In a 1998 to 1999 Scottish audit of 319 people, pain had usually been present for about 3 months, and 82% could not walk unaided by the time of diagnosis14. | Spinal metastases warning signs and can back pain be a sign of cancer? |
| Spinal infection, including spinal abscess (a pocket of pus near the spinal cord) | Back pain with a fever, shivers or feeling generally unwell16 | A US analysis estimated that about 37% of all spinal abscess cases end in death or permanent disability linked to a missed or delayed diagnosis7. | Back pain with fever |
Days to weeks
| Condition | Warning signs | What the research shows | Read more |
|---|---|---|---|
| Hip fracture not seen on X-ray (occult hip fracture) | Hip pain after a fall, or not being able to walk or put weight on the leg normally (go to A&E)15 | Among older people with suspected hip fracture and an X-ray with no definite fracture, further imaging found a fracture needing surgery in about 39%13. In people aged 60 or over with a hip fracture, surgery within 48 hours was linked to a 20% lower risk of death within a year, but this comes from observational studies and the evidence is of low certainty18. | Hip fracture with a normal X-ray |
| Scaphoid fracture (a small wrist bone) | Pain at the base of the thumb after a fall on an outstretched hand | UK hand-surgery standards advise splinting the wrist when a scaphoid fracture is suspected but the X-ray looks normal, with a firm plan within 2 weeks19. | Wrist pain with a normal X-ray |
| Stress fractures (cracks from repeated load), especially of the hip | Pain that builds with activity, then pain at rest or at night | In 23 athletes with femoral neck (upper thigh bone) stress fractures, diagnosis took 14 weeks on average, and 7 (30%) had complications that needed major surgery; the authors could show a direct effect of delay in only 1 case20. | Hip stress fractures and delayed diagnosis of stress fractures |
| Avascular necrosis (bone death from poor blood supply) | Deep, persistent hip or shoulder pain that is getting worse | Joint-preserving surgery is mainly an option before the bone collapses; once the ball of the hip collapses, treatment usually moves to joint replacement21. | Avascular necrosis and early MRI and avascular necrosis of the shoulder |
| Locked knee, which can mean a displaced “bucket-handle” meniscal tear | A knee that suddenly cannot straighten after a twisting injury, or keeps giving way | A European surgeons’ consensus prefers earlier surgery when a meniscal repair is needed, and favours repairing a meniscus over removing part of it because long-term results are better; the evidence behind it is mostly of low quality22. | Locked knee or giving way |
Months to years
| Condition | Warning signs | What the research shows | Read more |
|---|---|---|---|
| Axial spondyloarthritis (inflammatory arthritis of the spine and pelvis) | Long-lasting back pain, often starting in early adult life, with morning stiffness that eases with movement | Across 64 studies, the average time from first symptoms to diagnosis was 6.7 years23. A review of 21 studies, mostly snapshots in time, generally linked longer delay to worse physical function, more damage on X-ray, more work disability and poorer quality of life, though this cannot prove cause24. | Inflammatory back pain |
| Early inflammatory arthritis, such as rheumatoid arthritis | Swollen, stiff joints, often in the hands or feet, worse in the morning | In a Dutch study of 598 people with rheumatoid arthritis, being first assessed 12 weeks or more after symptoms began was linked to a 1.3 times higher rate of joint damage on X-ray over 6 years8. | The first three months of inflammatory arthritis |
| Soft-tissue sarcoma (a rare cancer of fat, muscle or other soft tissue) | A lump that is growing, or is bigger than a golf ball, painful or not25 | At a UK specialist centre, bone and soft-tissue sarcomas in 1,460 people averaged 10.7 cm at diagnosis, and the outlook worsened as size increased; however, how long symptoms had lasted did not predict size25. | A lump under the skin and an elbow tumour found late |
These timings describe the conditions, not your personal risk. Most people with back pain, a sore joint or a lump have none of these problems.
Do you need a scan straight away?
Usually not. For new low back pain without warning signs, early routine scanning does not improve recovery26, and guidelines for back, neck, shoulder, hip and knee pain also advise using imaging selectively10.
- Serious causes are rare. In one primary care study, only 11 of 1,172 people (0.9%) with new low back pain had a serious cause, mostly fractures9.
- Routine early scans do not help. Six randomised trials with 1,804 people found that routine, immediate imaging for low back pain without signs of a serious cause did not improve pain or function, in the short term or at 6 to 12 months26.
- Guidelines agree. A review of 44 clinical guidelines found that the high-quality ones for back, neck and shoulder pain and for hip and knee osteoarthritis give consistent advice: check for red flags, use imaging selectively and monitor progress10.
When you probably do not need a scan
- New back or neck pain with no warning signs that is gradually improving.
- A minor sprain or strain you can walk or move on, which is getting better week by week.
- Pain that is following the recovery path your clinician expected.
- A scan “just to check” when the result would not change your treatment.
If new warning signs appear, or the pain stops improving, the answer can change.
What can early imaging show, and what can it miss?
Each test answers different questions, so the right one depends on what is suspected. See our guide to choosing between MRI and ultrasound for joint pain.
| Test | Good at showing | Limits |
|---|---|---|
| X-ray | Most fractures, dislocations, joint wear (osteoarthritis) and bone alignment. Quick and widely available. | Uses a small dose of radiation. Shows muscles, tendons and ligaments poorly. Some fractures are too subtle or too early to see4,13. |
| Ultrasound | Tendons, muscles and ligaments near the surface, fluid in joints and lumps under the skin. The joint can be moved during the scan, and it can guide injections. No radiation. | Cannot see inside bone and sees deep structures less well. The quality depends on the skill of the person scanning. |
| MRI (a scan using a strong magnet and radio waves) | Bone marrow (early stress fractures, bone bruising, avascular necrosis, infection, tumours), cartilage, menisci, ligaments, discs, nerves and the spinal cord. No radiation. | Takes longer, is not suitable with some implants and can be difficult with claustrophobia. It is very sensitive, so it often shows age-related changes that are not causing pain11,12. |
Why more scanning is not always better
Scans show anatomy, not pain. In people with no back pain, disc degeneration is seen in 37% of 20-year-olds and 96% of 80-year-olds, and disc bulges in 30% and 84% respectively11. In knees with no pain or injury, meniscal tears are seen in 4% of adults under 40 and 19% of those aged 40 or over12.
A scan works best when it answers a clear question and is read by someone who knows your symptoms. Otherwise an unexpected finding can lead to worry, more tests or treatment you do not need. Our articles on what decides MRI quality and understanding your MRI results explain more.
Early imaging is not a replacement for physiotherapy. A clear diagnosis helps physiotherapists and other clinicians target the right tissue and avoid loading an injury that needs protecting.
When should you ask for a diagnosis review?
When symptoms are not following the expected path, or new ones appear, it is reasonable to ask whether the working diagnosis is still right. That is part of good care. Signs it may be time to ask:
- Pain that is getting worse, or has not improved in the time you were told to expect.
- Back pain that does not ease with rest or is worse at night, weight loss you cannot explain, or feeling generally unwell16.
- Locking, giving way or swelling after an injury.
- Not being able to put weight on a leg or use an arm normally.
- A lump that is growing or is bigger than a golf ball25.
- Back pain with a past history of cancer14, or with risk factors for a spinal fracture such as a serious injury, long-term steroid tablets or age over 709.
Related articles show how these patterns can look: shoulder pain despite physiotherapy, front-of-knee pain labelled as tendonitis, heel pain from a calcaneal fracture and a sacral insufficiency fracture. Bone health and nutrition are closely linked, so we also cover the female athlete triad and bone marrow changes in severe undernutrition.
How to get a faster diagnosis, safely
- Act on red flags straight away. For any emergency sign above, go to A&E or call 999 (UK) or your local emergency number. Do not wait for a routine appointment or a scan16.
- Use the right level of care. A suddenly hot, swollen, painful joint, or back pain with a fever, needs assessment the same day: in the UK, go to A&E.
- Keep a short symptom diary. Note when it started, what changes it, night pain, fever, weight loss and treatments tried.
- Ask two questions at each review. “What else could this be?” and “What would make us change the plan?” Patients and families have unique insights into the diagnostic process2.
- Ask whether a scan would change the plan. If yes, ask which test and why.
- Bring what you have. Previous scan images and reports, a list of medicines, and any history of cancer, osteoporosis, steroid use or recent infection.
- Close the loop on results. Ask who will give you the result and when, and chase it if you hear nothing.
- Consider a second opinion if things do not fit. If your symptoms and scan report do not seem to match, a specialist can review the images. See our second opinion page.
Waiting times for scans vary by country, region and test. If you are waiting, ask how long it is likely to be and what to do if symptoms worsen meanwhile.
Reading this from outside the UK?
The medical information here applies wherever you live; what differs is how you reach care. In an emergency, call 112 in the EU, 911 in the US and Canada, 000 in Australia, or your local emergency number (999 or 112 in the UK). For non-urgent problems, start with your usual doctor and take the checklist above with you.
How LSRI can help
LSRI (London Sports and Rheumatology Imaging) is a doctor-led MSK imaging clinic for non-emergency problems. We do not provide emergency care, blood tests, biopsies or surgery. For any emergency sign above, go to A&E or call 999.
If a problem is not improving as expected, we offer:
- MRI, ultrasound and X-ray, reported by a Consultant MSK Radiologist. MRI starts from £375 per body part, including the scan, a specialist report and access to your images (from £425 with a consultation).
- Reports within 24 hours, from the team led by Dr Prashant Sankaye.
- Second opinions on scans and reports you already have: see our second opinion page.
- Consultations, including our lumps and bumps clinic, and ultrasound-guided injections once a diagnosis is clear.
Our clinics are at Harley Street (W1G 9QJ) and Harrow (HA2 7SJ). To book or ask a question, call 0203 633 5040.
Frequently asked questions
Why is early imaging important?
For a few conditions, such as cauda equina syndrome, spinal infection, some fractures and inflammatory arthritis, delay is linked to lasting harm, and the right scan at the right time helps start the right treatment5,7,8,18. For most everyday aches and pains, early imaging does not speed up recovery10,26.
Should I get an MRI straight away for back pain?
Usually not. In one primary care study, fewer than 1 in 100 people with new low back pain had a serious cause9, and routine early imaging for low back pain without warning signs did not improve pain or function26. Go to A&E or call 999 if you have numbness around the genitals or anus, bladder or bowel changes, or weakness in both legs16.
Can an X-ray miss a fracture?
Yes. In one large emergency department study, 3.7% of limb fractures were missed in the first X-ray reports, and the most common reason was that the break was subtle4. Some fractures, such as hidden hip fractures, may not show on X-ray at all and may need an MRI to be found13.
Can a scan show something that is not causing my pain?
Yes, and it is common. Disc bulges, worn discs and meniscal tears are often seen in people with no pain, and become more common with age11,12. This is why scan findings should be read alongside your symptoms and examination.
How long should I wait before asking about a scan if my pain is not improving?
There is no single time limit. The NHS advises seeing a GP if back pain has not improved after a few weeks of treating it at home16. Emergency signs mean you should seek help straight away, and other warning signs, such as unexplained weight loss or pain that is worse at night, are a reason to see a GP16.
References
- Singh H, Meyer AND, Thomas EJ. The frequency of diagnostic errors in outpatient care: estimations from three large observational studies involving US adult populations. BMJ Qual Saf 2014;23(9):727-731. doi:10.1136/bmjqs-2013-002627
- National Academies of Sciences, Engineering, and Medicine; Balogh EP, Miller BT, Ball JR, editors. Improving Diagnosis in Health Care. Washington (DC): National Academies Press; 2015. doi:10.17226/21794
- Guly HR. Diagnostic errors in an accident and emergency department. Emerg Med J 2001;18(4):263-269. doi:10.1136/emj.18.4.263
- Wei CJ, Tsai WC, Tiu CM, Wu HT, Chiou HJ, Chang CY. Systematic analysis of missed extremity fractures in emergency radiology. Acta Radiol 2006;47(7):710-717. doi:10.1080/02841850600806340
- Najjar E, Egu C, Akil H, Najjar S, AlAchkar M, Muscogliati R, et al. Reassessing the clock in cauda equina syndrome: a systematic review and meta-analysis of surgical timing and outcomes. Spine J 2026;26(9):1653-1670. doi:10.1016/j.spinee.2026.04.013
- NHS. Septic arthritis. Page last reviewed 3 September 2026. nhs.uk
- Newman-Toker DE, Nassery N, Schaffer AC, Yu-Moe CW, Clemens GD, Wang Z, et al. Burden of serious harms from diagnostic error in the USA. BMJ Qual Saf 2024;33(2):109-120. doi:10.1136/bmjqs-2021-014130
- van der Linden MPM, le Cessie S, Raza K, van der Woude D, Knevel R, Huizinga TWJ, et al. Long-term impact of delay in assessment of patients with early arthritis. Arthritis Rheum 2010;62(12):3537-3546. doi:10.1002/art.27692
- Henschke N, Maher CG, Refshauge KM, Herbert RD, Cumming RG, Bleasel J, et al. Prevalence of and screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain. Arthritis Rheum 2009;60(10):3072-3080. doi:10.1002/art.24853
- Lin I, Wiles L, Waller R, Goucke R, Nagree Y, Gibberd M, et al. What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review. Br J Sports Med 2020;54(2):79-86. doi:10.1136/bjsports-2018-099878
- Brinjikji W, Luetmer PH, Comstock B, Bresnahan BW, Chen LE, Deyo RA, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol 2015;36(4):811-816. doi:10.3174/ajnr.A4173
- Culvenor AG, Øiestad BE, Hart HF, Stefanik JJ, Guermazi A, Crossley KM. Prevalence of knee osteoarthritis features on magnetic resonance imaging in asymptomatic uninjured adults: a systematic review and meta-analysis. Br J Sports Med 2019;53(20):1268-1278. doi:10.1136/bjsports-2018-099257
- Haj-Mirzaian A, Eng J, Khorasani R, Raja AS, Levin AS, Smith SE, et al. Use of advanced imaging for radiographically occult hip fracture in elderly patients: a systematic review and meta-analysis. Radiology 2020;296(3):521-531. doi:10.1148/radiol.2020192167
- Levack P, Graham J, Collie D, Grant R, Kidd J, Kunkler I, et al. Don’t wait for a sensory level: listen to the symptoms. A prospective audit of the delays in diagnosis of malignant cord compression. Clin Oncol (R Coll Radiol) 2002;14(6):472-480. doi:10.1053/clon.2002.0098
- NHS. Broken hip. Page last reviewed 29 July 2026. nhs.uk
- NHS. Back pain. Page last reviewed 5 March 2026. nhs.uk
- Weston VC, Jones AC, Bradbury N, Fawthrop F, Doherty M. Clinical features and outcome of septic arthritis in a single UK Health District 1982-1991. Ann Rheum Dis 1999;58(4):214-219. doi:10.1136/ard.58.4.214
- Klestil T, Röder C, Stotter C, Winkler B, Nehrer S, Lutz M, et al. Impact of timing of surgery in elderly hip fracture patients: a systematic review and meta-analysis. Sci Rep 2018;8:13933. doi:10.1038/s41598-018-32098-7
- British Society for Surgery of the Hand (BSSH). Scaphoid fractures. BSSH Standards of Care for Hand Trauma (due for revision 2027). bssh.ac.uk
- Johansson C, Ekenman I, Törnkvist H, Eriksson E. Stress fractures of the femoral neck in athletes: the consequence of a delay in diagnosis. Am J Sports Med 1990;18(5):524-528. doi:10.1177/036354659001800514
- Mont MA, Cherian JJ, Sierra RJ, Jones LC, Lieberman JR. Nontraumatic osteonecrosis of the femoral head: where do we stand today? A ten-year update. J Bone Joint Surg Am 2015;97(19):1604-1627. doi:10.2106/JBJS.O.00071
- Kopf S, Beaufils P, Hirschmann MT, Rotigliano N, Ollivier M, Pereira H, et al. Management of traumatic meniscus tears: the 2019 ESSKA meniscus consensus. Knee Surg Sports Traumatol Arthrosc 2020;28(4):1177-1194. doi:10.1007/s00167-020-05847-3
- Zhao SS, Pittam B, Harrison NL, Ahmed AE, Goodson NJ, Hughes DM. Diagnostic delay in axial spondyloarthritis: a systematic review and meta-analysis. Rheumatology (Oxford) 2021;60(4):1620-1628. doi:10.1093/rheumatology/keaa807
- Yi E, Ahuja A, Rajput T, George AT, Park Y. Clinical, economic, and humanistic burden associated with delayed diagnosis of axial spondyloarthritis: a systematic review. Rheumatol Ther 2020;7(1):65-87. doi:10.1007/s40744-020-00194-8
- Grimer RJ. Size matters for sarcomas! Ann R Coll Surg Engl 2006;88(6):519-524. doi:10.1308/003588406X130651
- Chou R, Fu R, Carrino JA, Deyo RA. Imaging strategies for low-back pain: systematic review and meta-analysis. Lancet 2009;373(9662):463-472. doi:10.1016/S0140-6736(09)60172-0
Book an appointment
Call 0203 633 5040 or book online. Clinics at Harley Street (W1G 9QJ) and Harrow (HA2 7SJ). If you have emergency symptoms, go to A&E or call 999 instead.
About this article
Purpose: written by the LSRI clinical team to help the public recognise which bone, joint and spine problems are time-sensitive, when a scan helps and when it does not, and how to get an accurate diagnosis safely, based on the research and guidance listed above. It is general information, not a diagnosis. If you are worried about your own symptoms, speak to your GP or, in an emergency, go to A&E. This article does not describe any individual patient and is not a criticism of any clinician.
