Protocol for Ordering X-rays of Bilateral Shoulders
For standard bilateral shoulder X-rays, order anteroposterior (AP), Grashey, axillary, and/or scapular Y projections as the core protocol, which provides comprehensive evaluation of both shoulders simultaneously. 1
Standard Bilateral Shoulder X-ray Protocol
- Order a complete set of views for each shoulder including:
- Anteroposterior (AP) view 1
- Grashey view (true AP with patient rotated 30-45° to project the glenohumeral joint without overlap) 1
- Axillary lateral view (shows anterior/posterior relationships and dislocations) 1
- Scapular Y view (alternative to axillary view, especially when patient mobility is limited) 1
Special Views Based on Clinical Suspicion
- For impingement syndrome: Add Rockwood view (upright 30° angled caudad radiograph) or suprascapular outlet view 1
- For suspected Bankart lesions: Add Westpoint view (prone position with shoulder on cushion, arm abducted 90°) 1
- For suspected Hill-Sachs deformity: Add Stryker notch view (supine with arm externally rotated and abducted, beam angled 10° cephalad) 1
Important Considerations
- Axillary views may be painful for patients with recent shoulder dislocations and could risk redislocation if the shoulder was recently reduced 1
- Clearly communicate clinical suspicion when ordering to ensure appropriate views are obtained 2
- For trauma cases, radiography is the mainstay of initial imaging, providing quick evaluation for fracture and dislocation 1
Clinical Pathway for Advanced Imaging
- If radiographs are noncontributory and further imaging is needed:
- For patients under 35 with suspected labral tear: MR arthrography is preferred (rated 9/9 for appropriateness) 1
- For suspected rotator cuff pathology: MRI without contrast or ultrasound (both rated 9/9 for appropriateness) 1
- For suspected septic arthritis: Ultrasound or X-ray guided arthrocentesis (both rated 9/9 for appropriateness) 1
Common Pitfalls to Avoid
- Ordering only AP views is insufficient for comprehensive shoulder evaluation 1
- Skipping radiographs and proceeding directly to MRI or ultrasound is not recommended - radiographs should be the first imaging study 3, 4
- Ordering MRI without prior radiographic evaluation leads to unnecessary imaging and costs 4
- Failing to include clinical information when ordering can result in inadequate views being obtained 2, 5
Remember that radiography remains the foundation of shoulder imaging evaluation, providing essential information about bony structures, alignment, and some soft tissue abnormalities before considering advanced imaging techniques 1, 3.