After a bilateral shoulder fall, what imaging studies and laboratory tests should be ordered?

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Last updated: September 28, 2026 • View editorial policy

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Bilateral Shoulder Radiographs First, Then CT or MRI Based on Findings

For a patient with bilateral shoulder trauma from a fall, order bilateral shoulder radiographs immediately (AP views in internal and external rotation plus axillary or scapula-Y views), then advance to CT without contrast for fracture characterization or MRI without contrast for soft tissue injury assessment based on initial radiographic findings. 1

Initial Imaging: Bilateral Shoulder Radiographs

Start with bilateral shoulder radiographs as the first-line imaging study for any acute shoulder pain following trauma 1, 2. The standard trauma series must include:

  • Anteroposterior (AP) views in both internal and external rotation
  • Axillary or scapula-Y view (critical—glenohumeral and acromioclavicular dislocations are frequently missed on AP views alone) 1, 2
  • Obtain upright films when possible, as supine positioning can underrepresent shoulder malalignment 2

Radiographs effectively identify displaced fractures, shoulder malalignment, and most fractures of the proximal humerus, clavicle, and scapula—the primary concerns in acute bilateral shoulder trauma 1.

Next Steps Based on Radiographic Results

If Radiographs Show Fracture (Proximal Humerus, Scapula, or Clavicle)

Order CT shoulder without IV contrast bilaterally 1. CT provides:

  • Superior characterization of complex fracture patterns and comminution
  • Detection of subtle nondisplaced fractures (changes management in up to 41% of proximal humeral fractures) 1
  • Essential pre-surgical planning for unstable or significantly displaced fractures 1

Exception: If the patient is NOT a surgical candidate and rotator cuff injury assessment is needed, consider MRI shoulder without contrast instead 1.

If Radiographs Show Dislocation or Instability

Order MRI shoulder without IV contrast bilaterally 1. In acute dislocation:

  • Post-traumatic joint effusion or hemarthrosis provides natural contrast for soft tissue visualization
  • MRI identifies labral tears, rotator cuff tears, Hill-Sachs lesions, and Bankart lesions 1, 2
  • No need for MR arthrography in the acute setting—the joint effusion serves this purpose 1

Alternative: CT without contrast is appropriate if MRI assessment of bone loss is limited or contraindicated 1.

If Radiographs Are Normal or Nonspecific but Clinical Suspicion Remains High

Choose between two equally appropriate options 1:

Option 1: CT shoulder without IV contrast if suspecting occult fracture

  • High spatial resolution for detecting subtle nondisplaced fractures
  • Particularly useful for scapular fractures frequently missed on radiographs 1

Option 2: MRI shoulder without IV contrast if suspecting soft tissue injury

  • Demonstrates bone marrow edema from occult fracture
  • Identifies rotator cuff tears, labral tears, and capsuloligamentous injuries 1
  • In patients ≥40 years with acute trauma, 38% have full-thickness rotator cuff tears or occult avulsion fractures 3

If Clinical Examination Suggests Rotator Cuff Tear

Order MRI shoulder without IV contrast OR ultrasound shoulder bilaterally 1. These are equivalent alternatives:

MRI preferred when:

  • Large body habitus limits ultrasound
  • Restricted range of motion from acute pain
  • Suspicion of other intra-articular pathology (labral tears) 1

Ultrasound acceptable when:

  • High-quality operator available
  • Focused assessment for full-thickness rotator cuff tears (90-91% sensitivity, 93-95% specificity) 1
  • Caveat: Ultrasound has variable performance for partial-thickness tears and cannot assess intra-articular structures 1

Critical Clinical Pearls

Physical examination clues in patients ≥40 years (when radiographs are negative) 3:

  • Inability to abduct above 90°: 84% sensitivity, 71% specificity for full-thickness tear
  • Weakness in external rotation (small finger test): 66% sensitivity, 86% specificity
  • Combined: >90% sensitivity for supraspinatus/infraspinatus tears or occult avulsion fractures

Bilateral injuries warrant high suspicion for 4, 5:

  • Seizure activity
  • Electric shock
  • High-energy trauma
  • Associated neurovascular injuries or additional fractures

Do not order:

  • CT with IV contrast (no role in acute shoulder trauma) 1
  • FDG-PET/CT (no role in acute trauma evaluation) 1
  • MR arthrography in acute setting (joint effusion provides natural contrast) 1

Laboratory Tests

No routine laboratory tests are indicated for isolated bilateral shoulder trauma from mechanical fall. Consider labs only if:

  • Suspicion for pathologic fracture (order calcium, alkaline phosphatase, vitamin D)
  • Concern for seizure as mechanism (order electrolytes, glucose, toxicology screen)
  • Signs of infection (order CBC, ESR, CRP)

The 2025 ACR Appropriateness Criteria provide the most current evidence-based framework for this clinical scenario 1, superseding the 2018 guidelines 2 with updated recommendations that emphasize the equivalence of ultrasound and MRI for rotator cuff assessment and clarify when MR arthrography is unnecessary in acute trauma.

References

1
Guideline

acr appropriateness criteria® acute shoulder pain: 2024 update.

Journal of the American College of Radiology, 2025

2
Guideline

acr appropriateness criteria<sup>®</sup> shoulder pain-traumatic.

Journal of the American College of Radiology, 2018

4
Research

Bilateral anterior shoulder dislocation: A case report.

Ulusal travma ve acil cerrahi dergisi = Turkish journal of trauma & emergency surgery : TJTES, 2024

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This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.