Physical Therapy Imaging: State rules, education, regulation

Physical therapists ability to order imaging has been a hot topic for some time now. Physical therapists have been pushing for more autonomy ever since switching from masters to a doctorate degree. Physical therapists are experts in musculoskeletal disease and injury having diagnostic capabilities just as precise as orthopedic surgeons.

One question that many therapists have is with all this knowledge why can’t I order imaging for my patients? In current practice the ability to order imaging is a very grey issue. Some states allow it, others do not, and many haven’t taken a position on it entirely. In most settings a therapist cannot order imaging, but in others they can with special training.

With all the greyness and variables we will break down some commonly asked questions surrounding physical therapists and diagnostic imaging. We will break into topics such as the knowledge base that therapist’s have that gives them this privilege or doesn’t, in what situations it is allowed, and what should happen in the future.

Do Physical Therapists Need To Know About Diagnostic Imaging?

Diagnostic imaging has only been universally required in all accredited Doctor of Physical Therapy Programs since 2016, however ever since the the advent of the DPT degree in 2005 it has been increasingly made a requirement across the country.

There is no standard for expected depth and breadth of imaging content, but a research report from 2014 surveyed 155 accredited DPT programs in the United States, and 98.1% reported including imaging in their curricula (1). Of these 155 program the average number of total contact hours was 24.4 hours.

This report is almost 10 years old and there has been much change and conversation since them. While there isn’t any new studies since then, many states and the APTA have been advocating for more referral privilege’s for diagnostic imaging. To follow suite many universities have been putting more emphasis on diagnostic imaging to prepare students to the future change in practice privilege’s.

Can Physical Therapists Order Imaging (MRI, Xrays, CT’s and Ultrasound) ?

It is possible for physical therapists to order imaging, but there are many variables that come into play before a therapist can do so. According to APTA only 7 states and the District of Columbia expressly permit physical therapists to order imaging (MRI, xray, CT, etc).

Physical therapists in the military have been able to order imaging since 1972 as musculoskeletal-expert “physician extenders.” So if you work in the military you have rights to order imaging, but you need additional imaging training to be considered competent.

There is one imaging modality that physical therapists explicitly have rights to utilize which is ultrasound. Ultra sound has the power to decrease healthcare costs and speed up the delivery of healthcare services. With extra training a physical therapist can get certified in musculoskeletal sonography and provide imaging instantly in the clinic. While it is not diagnostic it allows for instant confirmation of examination findings or potential red flags that indicate leving up the patient in the healthcare continuum.

What States Allow Physical Therapists To Order Imaging?

Currently the only states that explicitly have expressed that physical therapy can order imaging is Colorado, Wisconsin, District of Columbia, Maryland, Utah, new jersey and Utah(2,5). Many states however are silent on the topic and do not have any mention of the issue one way or another (3). This puts the ordering of imaging in a grey area in most states.

This might be a good thing you may think. You might say “hey well it doesn’t say ‘I cannot refer for imaging’ so I will do it anyway”, and you would not be wrong. The issue comes into play when insurance is expected to cover the charge. If it is not in the practice act of that state the insurance does not have to cover the charges. This is why it is important for the advocacy of the profession to let legislators and insurance companies know what value our profession is capable of adding to healthcare.

Should Physical Therapists Be Allowed To Order Imaging?

There are many arguments for physical therapists to be able to order imaging. Access to imaging decreases lag in the delivery of healthcare services, physical therapists have shown to be competent in accurately and selectively ordering imaging, and it decreases burden on an already overstretched healthcare system.

Firstly, being that physical therapists are direct access providers and experts in musculoskeletal disorders it is most appropriate for a patient who is experiencing a disorder that seems musculoskeletal in nature to seek help from a PT first.

If in that instance the practitioner catches red flags that indicate the need for further imaging it is in no ones interest that that therapist then refer to a physician, who then needs to refer to a radiologist, who then sends the results back to the physician, who then sends it to the physical therapist. This exchange takes an enormous amount of time from all parties involved when it could have been a simple one stop referral.

Next, many studies have shown from PT’s in the military and from the few states who grant access, that therapists who have access to imaging did so judiciously and demonstrated appropriate use of diagnostic imaging (4). Therapists who are trained in ordering imaging have been shown to exercise the same level of precision as orthopedic physician’s (1).

Lastly, physical therapists have the potential to dramatically decrease the epidemic of healthcare burnout. For many years now and at a rapid increase since the pandemic of 2020 all members of healthcare, but most notably physicians, have been experiencing burnout. One factor that has contributed to this is improper delegation of tasks. What more can the experts of the musculoskeletal system do to support this issue but to take the burden of assessing a patient with a musculoskeletal disorder who needs imaging.

Bonus examples:

Here are a couple real life examples taken from professors at the University of Maryland Baltimore’s Physical Therapy Program

The first shows how PT’s with these privilege’s can help their patients.

A colleague of mine was seeing a patient who had shoulder symptoms that was not getting better with conservative treatment so he ordered imaging to rule out a ligamentous injury.

After receiving the results the patient had a tumor in her shoulder that was successfully treated partly because of early intervention

The next example shows how frustrating not having these privilege’s can be for both the patient and the therapist.

I was seeing a patient who I was evaluating for low back pain. In our initial eval she expressed difficulty with voiding her bladder. Immediately I stopped and referred for imaging due to suspicion of cauda equina.

The referring physician will not order the test because she had imaging 3 years ago…. the symptoms only started recently.

What is more frustrating than knowing exactly what to do to help a patient and not being able to because of a road block you have no control over.


With all the grey physical therapy has taken their stance on what they want in the future to come. The question that still has to be answered is what will the legislators do when confronted with this in the coming years of advocacy.

It will be a great tool for the healthcare system for therapists to spread out the burden of patient services and put their doctorate degree to proper use by tapping into their advanced knowledge of anatomy, physiology, and disease.


(1) BOISSONNAULT WG, WHITE DM, CARNEY S, MALIN B, SMITH W. Diagnostic and Procedural Imaging Curricula in Physical Therapist Professional Degree Programs. Journal of Orthopaedic & Sports Physical Therapy. 2014;44(8):579-586.


(3) Keil AP, Hazle C, Maurer A, et al. Referral for Imaging in Physical Therapist Practice: Key Recommendations for Successful Implementation. Physical therapy. 2021;101(3). doi:10.1093/ptj/pzab013

(4) Aaron P Keil, Brian Baranyi, Sameer Mehta, Amma Maurer, Ordering of Diagnostic Imaging by Physical Therapists: A 5-Year Retrospective Practice Analysis, Physical Therapy, Volume 99, Issue 8, August 2019, Pages 1020–1026,


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