Which statement about radiographs in early rheumatoid arthritis is true?

• A. X-ray is the best initial imaging modality for RA.
• B. Anti-CCP antibodies are the best initial test for RA.
• C. RF levels reliably diagnose RA.
• D. X-ray can be normal for the first 6 months.

Answer: (D)

In early rheumatoid arthritis, imaging findings on plain X-ray often lag behind symptoms. The disease starts with synovial inflammation and swelling, and bone erosions or joint-space narrowing—what X-rays detect—take time to develop. As a result, X-rays can be normal during the first several months, including the first six months. This is why X-ray isn’t the best initial imaging modality when RA is suspected; more sensitive techniques like ultrasound or MRI can reveal early synovitis and erosions. Lab tests (RF and anti-CCP) help with diagnosis, but they aren’t imaging studies, and RF can be present in other conditions and may be negative early on.