X-ray Protocol for Shoulder Pain Evaluation
For patients presenting with anterior, posterior, and superior shoulder pain, a standard radiographic evaluation should include at least three views: anteroposterior (AP) view, external rotation view, and axillary or scapular Y view, as recommended by the American College of Radiology. 1
Standard Radiographic Views
The recommended radiographic protocol includes:
Anteroposterior (AP) view
- Most effective view, detecting approximately 88% of injuries 2
- Provides visualization of glenohumeral joint space, humeral head, and glenoid
- Should be performed first in all cases of shoulder pain
External rotation view
- Complements the AP view by showing different aspects of the glenohumeral joint
- Helps visualize the greater tuberosity and anterior glenoid rim
Axillary or scapular Y view
- Critical for evaluating anterior/posterior dislocations
- Provides perpendicular view to the AP projection
- Essential for complete assessment as it shows injuries missed on AP view 2
- The axillary view is particularly valuable for detecting glenohumeral dislocations
Clinical Considerations
- These three views represent the minimum standard for initial shoulder pain evaluation
- The axillary view is particularly important as it provides visualization of the shoulder joint from a different angle, helping to detect pathologies missed on frontal views 1, 2
- For comprehensive assessment in complex cases, additional views may be considered:
When to Consider Advanced Imaging
- If plain radiographs are noncontributory but symptoms persist, MRI without contrast is the preferred next step for evaluating soft tissue pathology 1
- CT without contrast may be considered if better fracture characterization is needed 1
- For suspected labral tears, MR arthrography is the gold standard, especially in patients under 35 years of age 1
Common Pitfalls to Avoid
- Inadequate imaging: Relying on a single view (typically just AP) is insufficient and may miss important pathology
- Improper technique: Poor positioning can lead to missed diagnoses
- Failure to obtain perpendicular views: At least two views at right angles to each other are essential for proper evaluation 2
- Not considering clinical context: The choice of specific projections should be guided by the patient's symptoms and physical examination findings 2
By following this standardized approach to shoulder radiography, clinicians can ensure a comprehensive initial evaluation of shoulder pain that affects the anterior, posterior, and superior aspects of the shoulder.