When is an X-ray (X-ray) recommended for shoulder pain or injury?

When to Order Shoulder X-rays

X-ray is the preferred initial imaging study for all patients presenting with traumatic shoulder pain and should include at minimum three views: anteroposterior (AP) in internal and external rotation, plus an axillary or scapula-Y view. 1

Indications for Shoulder X-ray

Traumatic Shoulder Pain (Always Obtain X-ray)

• Any history of trauma, fall, or acute injury mechanism warrants immediate radiographic evaluation 1, 2
• X-ray effectively identifies the two primary concerns requiring urgent management:
  • Fractures (clavicle, scapula, proximal humerus) 1
  • Dislocations (glenohumeral, acromioclavicular) 1
• Radiography should be performed upright because shoulder malalignment can be missed on supine films 1, 2

Clinical Predictors of Informative X-rays

When deciding whether X-ray will change management, consider these high-yield clinical features:

• Visible deformity on examination (strongest predictor—correctly identifies therapeutically important findings in 91% of cases) 3
• Age >43.5 years with history of precipitating fall (high likelihood of fracture) 3
• Patients without deformity AND without precipitating fall have essentially zero probability of informative X-ray findings 3

Essential Technical Requirements

Standard Three-View Series

The minimum acceptable trauma series must include 1, 2:

• AP views in internal and external rotation (or Grashey projection at 30° posterior oblique to profile the glenohumeral joint) 1
• Axillary lateral view OR scapular Y view (critical—dislocations are frequently misclassified on AP views alone) 1

Common Pitfall to Avoid

Failure to obtain axillary or scapula-Y views leads to missed diagnoses of glenohumeral and acromioclavicular dislocations 2. AP views alone are insufficient for trauma evaluation 1.

When X-ray is Overutilized

Non-Traumatic Shoulder Pain

• For atraumatic shoulder pain without the clinical predictors above, X-ray is frequently overutilized 3
• In emergency department studies, 80% of shoulder X-rays in patients without deformity or significant trauma were therapeutically uninformative 3
• However, X-ray remains appropriate as first-line imaging even for non-traumatic pain to rule out underlying pathology before proceeding to advanced imaging 4, 5

What X-ray Identifies

Conditions Requiring Acute Surgical Management

• Unstable or significantly displaced fractures 1, 2
• Joint instability/dislocations 1, 2
• These require immediate orthopedic referral 2

Conditions Amenable to Conservative Management

• Most soft-tissue injuries (labral tears, rotator cuff tears) can undergo conservative management initially 1
• Note: X-ray will not visualize these soft-tissue injuries—MRI or ultrasound is required if clinical suspicion persists after normal radiographs 1

When to Proceed Beyond X-ray

If radiographs are non-contributory but clinical concern persists:

• Age <35 years with suspected labral tear/instability: MR arthrography (gold standard) 1
• Suspected rotator cuff pathology: MRI without contrast or ultrasound (with appropriate expertise) 1
• Need for fracture characterization: CT if more preoperative detail required 1