This qualitative study describes how physical therapist experts in musculoskeletal disorders evaluate and interpret imaging studies and how they employ imaging in clinical decision-making. The informants are physical therapists who are certified orthopedic clinical specialists (OCS) and/or fellows of the American Academy of Orthopaedic Manual Physical Therapists (AAOMPT). The study employed web conferencing to display patient cases, record screen-capture videos, and to conduct interviews. Informants were observed and their activity video-captured as they evaluated imaging studies and, afterwards, interviews were employed to explore the processes they utilized to evaluate and interpret the images and to discuss imaging-related clinical decision-making, including possible functional consequences of changes seen in the images, contraindications to treatment, and indications for referral. The interviews were transcribed and analyzed in the tradition of grounded theory. This study found that the informants’ evaluation of imaging studies was contextual and non-systematic, guided by the clinical presentation. The informants used imaging studies to provide a deeper understanding of clinical findings and widen perspectives, arriving at clinical decisions through the synthesis of imaging, clinical findings, and didactic knowledge. They tended to look for imaging evidence of interference with normal motion, rather than evidence of pathology. Overall, the informants expressed conservative views on the use of imaging, noting they would rather use clinical findings and treatment response than imaging findings as a basis for referral to other health care professionals. Using imaging studies to support clinical decision-making can provide physical therapists a wider perspective when planning treatment interventions. By showing physical therapists’ approach to interpreting imaging studies and how this relates to their clinical decision-making, the findings of this study could contribute to discussions of the place of imaging in physical therapist practice, as well as help set objectives for imaging curricula in professional-level and continuing education.