08/17/2026
Do We Always Need the Radiation? Rethinking Medical Imaging for Patients With FQAD — and for All of Us
By Jerzy Tyszkowski - Fluoroquinolone Toxicity Study NFP
Modern medicine has extraordinary imaging technologies capable of revealing diseases that physicians could not have detected only a few generations ago. Conventional X-rays, computed tomography (CT), mammography, fluoroscopy, nuclear medicine, and positron emission tomography (PET) can be essential and, in many circumstances, lifesaving. Magnetic resonance imaging (MRI) and diagnostic ultrasound offer additional ways of looking inside the human body. Yet an important distinction among these technologies is too often overlooked by patients: conventional X-rays, CT, mammography, fluoroscopy, nuclear medicine, PET, and PET/CT involve ionizing radiation, whereas ultrasound and MRI do not.
♦️Why Ultrasound May Be Useful For FQAD
This distinction deserves particular consideration for patients with Fluoroquinolone-Associated Disability (FQAD), although the underlying principle applies to everyone. The European Medicines Agency has formally warned that fluoroquinolones can produce long-lasting, disabling, and potentially permanent adverse effects involving tendons, muscles, joints, and the nervous system.[1] These effects can include tendon inflammation and rupture, muscle pain and weakness, joint pain and swelling, difficulty walking, and neurological abnormalities.
Many patients with persistent fluoroquinolone-associated problems consequently undergo repeated investigations of the Achilles tendons, shoulders, wrists, hands, fingers, knees, muscles, joints, and peripheral nerves. These are also precisely the kinds of structures that modern high-resolution musculoskeletal ultrasound can often evaluate. Patients sometimes still think of ultrasound primarily as a technology used during pregnancy or for abdominal examinations. Modern musculoskeletal ultrasound is much more than that.
➥ High-frequency ultrasound can visualize:
• tendon thickness and fibrillar architecture
• tendinopathy
• partial and complete tendon tears
• tendon sheaths
• tenosynovitis
• bursae and fluid collections
• selected ligament abnormalities
• muscle structure and injuries
• joint effusions
• synovial abnormalities
• entheses where tendons attach to bone
• superficial masses and cysts
• calcifications
• selected peripheral nerves
Doppler ultrasound can additionally provide information about vascularity associated with certain inflammatory processes. Perhaps most importantly, ultrasound is a dynamic examination. The examiner can watch a tendon move, observe a muscle during contraction, follow a nerve or tendon through movement, compare the symptomatic structure with the opposite side, and place the probe directly over the area where the patient reports pain. The FDA confirms that ultrasound uses high-frequency sound waves, provides real-time imaging, and, unlike X-ray imaging, does not expose the patient to ionizing radiation.[2]
This becomes particularly interesting when clinical practices are compared internationally. Musculoskeletal ultrasound has been integrated into rheumatology and musculoskeletal medicine across numerous European countries, although implementation varies considerably. A European survey involving EULAR member countries found substantial use of musculoskeletal ultrasound, with rheumatology listed among the principal specialties performing it in 64.5% of responding countries. Ultrasound education had also become part of rheumatology training curricula in more than half of the surveyed countries.[3] European professional organizations have developed standardized ultrasound techniques for anatomical regions including the shoulder, wrist, hand, knee, ankle, and Achilles tendon.
A European patient suffering from persistent problems following fluoroquinolone exposure recently described her own experience to us. Her orthopedist initially used ultrasound to examine her shoulders, wrist, fingers, Achilles tendon, and neck muscles. According to her description, conventional radiography was reserved primarily for situations in which a fracture or another bone abnormality was suspected. Her ultrasound examinations demonstrated structural changes, fluid, and inflammatory abnormalities in soft tissues.
One patient’s experience is not scientific evidence and should not be presented as such. However, it raises an important question about diagnostic culture: when the suspected pathology lies primarily in a tendon, muscle, tendon sheath, bursa, or accessible peripheral nerve, should high-quality ultrasound be considered more frequently before proceeding to other forms of imaging?
The Achilles tendon is an obvious example for the FQAD population. Fluoroquinolone-associated tendon injury is well recognized by regulators.[1] If a physician suspects a fracture or significant bone abnormality, conventional radiography may be entirely appropriate. But when the clinical question concerns the tendon itself, ultrasound can evaluate its thickness, architecture, areas of tendinopathy, partial or complete rupture, and surrounding soft tissues. It can also be repeated over time without exposing the patient to ionizing radiation.
The same principle applies to many shoulder abnormalities. A systematic review and meta-analysis involving 23 studies and more than 2,000 shoulders found strong diagnostic performance for ultrasound in rotator-cuff disease when performed by experienced operators. In studies directly comparing ultrasound with MRI, no statistically significant difference was found in sensitivity, specificity, or accuracy for supraspinatus tears.[4] That does not mean that ultrasound replaces MRI. It demonstrates that, for selected clinical questions, a less complex examination can sometimes provide substantial diagnostic information.
MRI remains indispensable. It can visualize bone marrow, deep structures, and many intra-articular abnormalities that ultrasound cannot adequately assess. It is also important to emphasize that MRI does not use ionizing radiation. Therefore, the argument presented here is not “ultrasound instead of MRI,” nor is it “ultrasound instead of every X-ray.” It is more rational than that: use the imaging modality capable of answering the clinical question while avoiding unnecessary exposure, expense, and complexity whenever possible. The reason this deserves renewed attention extends far beyond FQAD. Ionizing radiation is not biologically inert. X-rays and gamma radiation are classified by the International Agency for Research on Cancer as carcinogenic to humans.[5] Ionizing radiation has sufficient energy to ionize biological molecules and can damage DNA.
This does not mean that every diagnostic X-ray causes cancer or that medically indicated radiological examinations should be refused. The diagnostic information obtained from CT, radiography, mammography, PET, and nuclear medicine can save a patient’s life. The radiation itself, however, is not the therapeutic benefit. The benefit comes from the diagnostic information obtained through the exposure. Consequently, when exposure is necessary and justified, its benefit may greatly exceed its potential risk. When an equally appropriate non-ionizing examination can provide the same necessary information, the balance is different.
A major study published in JAMA Internal Medicine in 2025 makes this discussion particularly timely. Smith-Bindman and colleagues estimated that approximately 93 million CT examinations were performed in about 62 million patients in the United States in 2023.[6] Using contemporary CT utilization, organ-dose estimates, and established radiation-risk models, the investigators projected approximately 102,700 future cancers associated with radiation from those examinations. Their analysis estimated that, if current CT utilization and radiation-dose practices persist, CT-associated malignancies could eventually account for approximately 5% of new cancer diagnoses annually in the United States.[6]
These numbers require responsible interpretation. The study did not observe 102,700 people developing cancer and prove that each cancer resulted from CT. It was a population-level lifetime risk projection. Nevertheless, the magnitude of the estimate is difficult to ignore, and the authors themselves emphasized the importance of justifying CT use and optimizing radiation dose.
♦️Why Cumulative Radiation Deserves Consideration
An even more important observation emerged from a very large study of children and adolescents published in the New England Journal of Medicine in 2025. Investigators followed 3,724,623 children and adolescents, encompassing more than 35 million person-years of observation.[7] They examined cumulative radiation exposure to active bone marrow from medical imaging and subsequent hematologic malignancies. Risk increased with increasing cumulative radiation dose. The investigators estimated that 10.1% of hematologic cancers in this specific cohort could be attributable to radiation from medical imaging, with a 95% confidence interval of 5.8% to 14.2%.[7]
This is an extremely important distinction: the finding does not mean that 10–15% of all cancers in the general population are caused by diagnostic imaging. It concerns the estimated attributable fraction of hematologic cancers in this particular pediatric and adolescent cohort. Nevertheless, it reinforces the principle that cumulative medical radiation should not simply be regarded as biologically irrelevant.
♦️Mammography Requires A Balanced Discussion
Mammography presents an especially important and more complicated example. Mammography uses low-dose X-rays and therefore exposes breast tissue to ionizing radiation. Multiple peer-reviewed publications have examined radiation-induced breast-cancer risk associated with repeated mammographic screening.[8–10] Miglioretti and colleagues modeled annual screening of 100,000 women from ages 40 through 74 and projected approximately 125 radiation-induced breast cancers and 16 deaths from those cancers.[8] At the same time, the same analysis projected approximately 968 breast-cancer deaths prevented through screening.
That comparison is essential. The study does not support abandoning mammography. It demonstrates something more sophisticated and scientifically important: a diagnostic procedure can carry a small radiation-associated carcinogenic risk while simultaneously providing a substantially greater population-level benefit through earlier cancer detection.
Other investigators have independently examined radiation-induced breast-cancer risk from mammographic screening.[9] A dedicated review titled Breast Cancer Induced by X-Ray Mammography Screening? examined the issue in the context of low-dose radiobiology.[10] Therefore, it would be inaccurate to describe radiation-associated carcinogenesis from mammography as a subject for which no scientific literature exists. At the same time, it would be equally inaccurate to tell women simply to replace mammography with ultrasound. Breast ultrasound and mammography visualize different pathological features. Mammography can reveal microcalcification patterns associated with ductal carcinoma in situ and early malignancy that ultrasound may not reliably detect. Breast ultrasound and, in selected circumstances, MRI can provide important additional information without ionizing radiation, but the optimal modality depends on age, breast density, family history, genetic susceptibility, symptoms, and previous findings.
The rational question is not, “Should I refuse mammography?” but rather, “Considering my individual risk, is this the appropriate examination, and could ultrasound or MRI provide useful complementary or alternative information in my particular situation?”
♦️Lessons From Patients With Scoliosis
The history of patients with scoliosis provides another important warning about cumulative diagnostic radiation. Historically, children and adolescents with spinal deformities frequently underwent repeated full-spine radiographs during years of growth and clinical surveillance. Long-term follow-up of women repeatedly exposed to diagnostic X-rays for scoliosis and other spinal disorders subsequently identified increased breast-cancer risk and mortality, including evidence linking estimated radiation dose to subsequent breast-cancer risk.[11,12]
A later systematic review and meta-analysis encompassing more than 35,000 scoliosis patients examined cancer and mortality risks associated with repeated radiographic exposure and emphasized the importance of reducing radiation exposure during long-term surveillance when clinically feasible.[13] These patients illustrate a principle that applies far beyond scoliosis: an individually small exposure is not necessarily equivalent to cumulative exposure accumulated over years or decades. A person’s lifetime medical-imaging history can include dental X-rays, chest X-rays, spinal radiographs, mammography, fluoroscopic procedures, emergency CT examinations, repeated CT surveillance, nuclear-medicine studies, and PET examinations. Each may have been individually justified. But cumulative exposure should still matter when clinicians decide whether another ionizing examination is necessary.
♦️PET
PET deserves particular attention because patients may not realize that it also involves ionizing radiation. Unlike conventional radiography, in which radiation originates outside the body, PET requires administration of a radioactive radiotracer. The emitted radiation is then detected to construct functional and metabolic images. PET can provide extraordinarily valuable information in oncology, cardiology, neurology, and other fields, and medically necessary PET should not be discouraged. However, PET is not radiation-free. In PET/CT, exposure can arise from both the radioactive PET tracer and the CT component. The magnitude depends on the tracer, administered activity, patient characteristics, and the CT protocol.
PET/MRI can eliminate the CT component of the exposure because MRI itself does not use ionizing radiation, but PET/MRI still involves radiation from the radioactive tracer. This distinction is important: a lower-radiation examination is not necessarily a zero-ionizing-radiation examination.
♦️ Fluoroscopy & Conventional Nuclear Medicine
Fluoroscopy and conventional nuclear medicine should also be included in this discussion. Fluoroscopy uses X-rays to produce real-time images and can result in substantially different radiation doses depending on procedure type and duration. Nuclear medicine introduces radioactive material into the patient to provide functional information. These technologies have indispensable clinical applications. Their inclusion here is not an argument against their use. It is a reminder that, when discussing a patient’s cumulative medical-radiation exposure, CT is only one part of the picture.
♦️Understanding Low-Dose Radiation Risk/FQAD
The concept that a low dose should not automatically be equated with zero biological interaction is also important. At very low radiation doses, individual cancer risk becomes difficult to measure epidemiologically, and scientific uncertainty increases. It would therefore be excessive to claim that every arbitrarily small dose produces measurable disease in every person. But uncertainty at low doses is not evidence that ionizing radiation becomes biologically beneficial or completely inert. Radiation protection has therefore developed around the principles of justification and optimization: perform an ionizing examination when its expected clinical benefit warrants the exposure, and, when it is necessary, obtain the required diagnostic information with an appropriately optimized dose.
This principle is particularly relevant to people with chronic diseases who may undergo many diagnostic procedures during their lifetimes. Patients with FQAD represent one such population. There is currently no evidence establishing that medically indicated diagnostic radiation uniquely worsens FQAD, and we should not make that claim without data. What we can say is that some patients with FQAD experience multisite tendon, muscle, joint, and neurological symptoms and may therefore undergo repeated imaging. Avoiding unnecessary ionizing radiation in such patients follows the same radiation-protection principles that should apply to everyone.
♦️Future Research
This also creates an important research opportunity. A standardized high-resolution ultrasound protocol could potentially examine Achilles tendons, patellar and quadriceps tendons, rotator-cuff and biceps tendons, wrist and hand tendons, selected muscles, entheses, and selected peripheral nerves in patients with persistent FQAD. Investigators could measure tendon thickness, echotexture, fibrillar organization, focal structural defects, calcification, peritendinous fluid, Doppler vascularity where appropriate, muscle architecture, and nerve cross-sectional area. Symptomatic sites could be compared with contralateral structures, and patients could potentially be followed longitudinally without ionizing radiation.
Such research could begin answering questions that remain largely unexplored. Do patients with persistent FQAD demonstrate reproducible ultrasonographic abnormalities? Are the abnormalities multisite? Can structural abnormalities be demonstrated in tissues that appear relatively normal during routine physical examination? Do findings correlate with pain, weakness, or functional impairment? Are there identifiable patterns of tendon or muscle involvement following fluoroquinolone exposure? Do those abnormalities change during deterioration or recovery? Could high-resolution ultrasound eventually contribute objective imaging biomarkers for particular components of fluoroquinolone-associated musculoskeletal injury? We do not currently have sufficient evidence to answer these questions. That is precisely why systematic research would be valuable.
♦️Ultrasound and Appropriate Use
Patients should not refuse medically necessary imaging. CT, radiography, mammography, and PET can provide essential, sometimes lifesaving information. However, patients may reasonably ask whether ultrasound, MRI, or another non-ionizing method could adequately answer the clinical question. Ultrasound can be particularly useful for accessible tendons, muscles, bursae, ligaments, joint effusions, and peripheral nerves.
Although ultrasound introduces acoustic energy that can produce small thermal or mechanical effects, the FDA reports an excellent safety record and recommends prudent use by trained professionals.[2] Unlike X-ray imaging, ultrasound does not use ionizing radiation. Its effectiveness is highly operator-dependent, and its availability may be influenced by training, equipment, reimbursement, and referral practices. The goal is not to place one technology against another, but to select the most appropriate examination for each patient and clinical question.
♦️The Real Issue is Appropriate Imaging
Ionizing radiation has transformed medicine, but it is also a recognized carcinogenic exposure. The latest research provides additional reasons to take cumulative exposure seriously. A 2025 analysis projected approximately 103,000 future cancers associated with a single year of CT utilization in the United States under its modeling assumptions.[6] A cohort of almost 3.7 million children and adolescents demonstrated increasing hematologic-cancer risk with increasing cumulative radiation from medical imaging and estimated a 10.1% attributable fraction within that specific population.[7] Mammography modeling demonstrates a small projected radiation-induced breast-cancer burden while simultaneously demonstrating substantially greater expected benefits from appropriate screening.[8] Decades of observation of patients repeatedly radiographed for scoliosis provide another reminder that cumulative exposure deserves attention.[11–13]
♦️Conclusion
None of these findings justify abandoning medically necessary imaging. They support a simple principle: use CT, radiography, mammography, PET, or MRI when clinically appropriate—but consider ultrasound when it can adequately answer the same question.
This is particularly relevant to FQAD because tendons, muscles, joints, and nerves are among the structures potentially affected by fluoroquinolone adverse reactions.[1] High-resolution ultrasound may help document structural abnormalities while avoiding ionizing radiation, offering an underexplored diagnostic opportunity for a population in need of objective markers. The goal is not to abandon lifesaving imaging, but to use it intelligently: the right examination for the right patient and clinical question, without unnecessary radiation.
➥For more info on imaging visit our page: https://fq100.org/insights
✅Disclaimer: This article is provided for educational, scientific, and public-awareness purposes only. It does not constitute medical advice, diagnosis, or treatment recommendations and should not be used as a substitute for consultation with a qualified healthcare professional. Nothing in this article is intended to encourage patients to refuse, postpone, or discontinue medically indicated X-rays, CT scans, mammography, fluoroscopy, nuclear medicine, PET/PET-CT, or any other diagnostic procedure. These technologies can be essential and lifesaving when appropriately indicated.
✅Artificial Intelligence Disclosure: ChatGPT was used to assist with research, organization, fact-checking, and editing. The author reviewed all material and remains responsible for the article’s content, interpretations, and conclusions.
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References
[1] European Medicines Agency. Disabling and potentially permanent side effects lead to suspension or restrictions of quinolone and fluoroquinolone antibiotics. EMA; 2018.
[2] U.S. Food and Drug Administration. Ultrasound Imaging: Benefits/Risks. FDA.
[3] Naredo E, D’Agostino MA, Conaghan PG, et al. Current state of musculoskeletal ultrasound training and implementation in Europe: results of a survey of experts and scientific societies. Rheumatology (Oxford). 2010;49(12):2438–2443. doi:10.1093/rheumatology/keq243.
[4] Farooqi AS, et al. Diagnostic Accuracy of Ultrasonography for Rotator Cuff Tears: A Systematic Review and Meta-analysis. Orthopaedic Journal of Sports Medicine. 2021.
[5] International Agency for Research on Cancer. Ionizing Radiation, Part 1: X- and Gamma-Radiation, and Neutrons. IARC Monographs on the Evaluation of Carcinogenic Risks to Humans. Vol. 75. Lyon: IARC; 2000.
[6] Smith-Bindman R, Chu PW, Azman Firdaus H, et al. Projected Lifetime Cancer Risks From Current Computed Tomography Imaging. JAMA Internal Medicine. 2025;185(6):710–719. doi:10.1001/jamainternmed.2025.0505.
[7] Smith-Bindman R, Alber SA, Kwan ML, et al. Medical Imaging and Pediatric and Adolescent Hematologic Cancer Risk. New England Journal of Medicine. 2025;393:1269–1278. doi:10.1056/NEJMoa2502098.
[8] Miglioretti DL, Lange J, van den Broek JJ, et al. Radiation-Induced Breast Cancer Incidence and Mortality From Digital Mammography Screening: A Modeling Study. Annals of Internal Medicine. 2016;164(4):205–214. doi:10.7326/M15-1241.
[9] Yaffe MJ, Mainprize JG. Risk of radiation-induced breast cancer from mammographic screening. Radiology. 2011;258(1):98–105.
[10] Pauwels EKJ, Foray N, Bourguignon MH. Breast Cancer Induced by X-Ray Mammography Screening? A Review Based on Recent Understanding of Low-Dose Radiobiology. Medical Principles and Practice. 2016;25(2):101–109. doi:10.1159/000442442.
[11] Hoffman DA, Lonstein JE, Morin MM, Visscher W, Harris BS III, Boice JD Jr. Breast cancer in women with scoliosis exposed to multiple diagnostic X-rays. Journal of the National Cancer Institute. 1989.
[12] Ronckers CM, Land CE, Miller JS, Stovall M, Lonstein JE, Doody MM. Cancer mortality among women frequently exposed to radiographic examinations for spinal disorders. Radiation Research. 2010.
[13] Luan FJ, Wan Y, Mak KC, Ma CJ, Wang HQ. Cancer and mortality risks of patients with scoliosis from radiation exposure: a systematic review and meta-analysis. European Spine Journal. 2020.
