Structural damage progression in patients with established rheumatoid arthritis (RA) has traditionally been assessed by conventional radiography (CR), which has proven its value in clinical practice and clinical trials over the past decades. The most prominent abnormalities visualized by CR in RA patients are erosions as a consequence of bone destruction and joint space narrowing (JSN) as a consequence of cartilage damage. Several validated scoring systems to quantify the structural joint damage and progression herein are available. Computed tomography and magnetic resonance imaging are newer, more sensitive methods for detection and monitoring of structural joint damage. A validated scoring system for magnetic resonance imaging of the hands and wrists exists, while no consensus has been reached on a scoring system for computed tomography. Structural damage identified by either CR or magnetic resonance imaging predicts a poorer disease course in patients with both early and established rheumatoid arthritis.