If you’re dealing with persistent knee pain but your X-ray came back “normal,” it’s easy to feel confused or even dismissed. But here’s the truth: you can still have knee arthritis — even when your X-ray doesn’t show it.
This is far more common than people think, and it highlights why good clinical care goes beyond just a scan.
Why an X-ray Might Look Normal (Even When Something’s Wrong)
X-rays are a useful tool, but they have limitations. They primarily show bones — so they don’t give a clear picture of soft tissues like cartilage, ligaments, or the joint lining. Arthritis often starts in these softer structures and can be missed on early imaging.
Here’s what an X-ray won’t show well:
- Early cartilage wear: Cartilage is invisible on X-ray. By the time damage is visible, it’s often quite advanced.
- Joint inflammation: Swelling and irritation of the joint lining (synovitis) won’t show.
- Bone marrow stress: Painful internal changes in the bone, like edema (inflammation), don’t appear.
- Ligament and tendon issues: These soft tissues may be involved in your symptoms but are outside X-ray’s reach.
So if your knee pain is real (and we believe it is!), a clear X-ray doesn’t mean you’re imagining things. It just means the picture doesn’t tell the full story.
Why Some People Have Bad X-rays and No Pain (and Vice Versa)
Interestingly, the reverse is also true: some people have clear signs of arthritis on X-ray but little or no pain. This is because symptoms don’t always match up neatly with the images.
Pain is influenced by:
- Joint mechanics
- Inflammation
- Strength and stability around the knee
- Your activity levels and overall health
That’s why it’s so important not to rely on scans alone.
When Do You Need More Than an X-ray?
If your symptoms persist and aren’t explained by a normal X-ray, further investigation might be helpful.
MRI scans, for example, are much better at showing:
- Cartilage thinning or tearing
- Joint lining inflammation
- Bone marrow changes
- Ligament/tendon involvement
However, many diagnoses can be confidently made based on your symptoms, how your knee moves and responds during examination, and how you describe the impact on your life.
What You Can Do About It
If your knee pain is ongoing but your X-ray hasn’t shown much, don’t give up. There’s still a lot you can do to help yourself — and that starts with understanding that the absence of clear imaging changes doesn’t mean your pain isn’t valid.
As a physiotherapist, here’s what I recommend:
- Don’t wait for things to get worse. You don’t need to “prove” your arthritis to start looking after your joints.
- Work on strength and movement. This is the cornerstone of managing arthritis — even when scans look fine.
- Look at the full picture. Sleep, stress, footwear, and daily habits all affect how your joints feel.
- Seek professional guidance. A physio can assess you properly, explain what’s really going on, and guide you with exercises tailored to your specific needs. I have a full knee rehab program here – start today.
Confused by Your X-ray Report?
This blog breaks down what those terms actually mean — and what they don’t tell you.
Understanding Arthritic Knees Through X-rays and Images: What Do They Show?
The Bottom Line
Yes, you can absolutely have knee arthritis with a normal X-ray. Don’t let a “clear scan” keep you stuck or feeling like there’s no answer. Pain is real, and there are many steps you can take to improve how your knee feels and functions — regardless of what the image says.
You deserve care that sees you, not just your scan.
Take care, Helen
Helen Manders BSc (Hons) MCSP HCPC
Chartered Physiotherapist Since 2001
