What does a normal shoulder x-ray (x-ray) indicate and what are the next steps if symptoms persist?

Normal Shoulder X-Ray: Clinical Significance and Management Algorithm

If shoulder symptoms persist despite normal radiographs, proceed directly to MRI without IV contrast to identify soft tissue injuries, as this is the most appropriate next imaging study according to the most recent ACR guidelines. 1

What a Normal Shoulder X-Ray Indicates

A normal shoulder radiograph effectively excludes:

• Shoulder dislocation and most displaced fractures as the primary cause of pain 1
• Gross bony malalignment of the glenohumeral and acromioclavicular joints 1
• Obvious fractures of the proximal humerus, scapula, and clavicle 1

However, normal radiographs do not rule out the most common causes of shoulder pain, which are predominantly soft tissue injuries including rotator cuff tears, labral tears, bone marrow contusions, and ligamentous injuries. 1

Next Steps When Symptoms Persist

Immediate Next Imaging: MRI Without IV Contrast

MRI without IV contrast is the preferred next imaging modality for persistent acute shoulder pain with normal radiographs. 1

Why MRI is superior:

• Identifies soft tissue pathology including rotator cuff tears, osseous contusions, acromioclavicular sprains, and capsular/ligament tears 1
• Detects bone marrow contusions that are invisible on radiographs 1
• Evaluates acute intra-articular pathology using the joint effusion that typically accompanies acute trauma as natural contrast 1
• Superior to ultrasound for comprehensive evaluation, as ultrasound completely overlooks shoulder instability and bone contusion 2

Clinical Context Matters

For acute traumatic shoulder pain (post-injury):

• MRI without contrast is preferred over MR arthrography because acute trauma produces joint effusion that serves as natural contrast for assessing intra-articular structures 1
• MRI can establish underlying pathology in most cases, including rotator cuff tears, labral injuries, and occult fractures 1, 2

For suspected isolated rotator cuff pathology in older patients:

• Ultrasound may be considered as a screening tool, particularly in older populations where rotator cuff tears are more common 1
• However, ultrasound has significant limitations: it misses up to 40% of significant pathology and completely overlooks instability and bone contusions 1, 2
• Ultrasound sensitivity is only 73.3% with 81.3% accuracy for shoulder pathology 3

Alternative Imaging Considerations

CT without IV contrast should be reserved for:

• Suspected occult fractures when MRI is contraindicated 1
• Characterizing complex fracture patterns if subtle fractures are suspected 1
• CT is superior for detecting nondisplaced scapular fractures frequently missed on radiographs 1

MR arthrography is NOT appropriate in the acute setting:

• Reserved for subacute or chronic presentations where joint effusion has resolved 1
• Superior for detecting labroligamentous injuries and partial-thickness rotator cuff tears in non-acute settings 1

Common Pitfalls to Avoid

Do not rely on ultrasound alone for comprehensive evaluation:

• Ultrasound has 0% positive predictive value for instability 2
• Completely misses bone contusions and many soft tissue injuries 2
• Limited utility when pain cannot be localized to rotator cuff or biceps tendon 1

Do not order bone scan, PET/CT, or CT arthrography:

• No relevant literature supports these modalities for acute shoulder pain with normal radiographs 1
• These are not appropriate next imaging studies 1

Do not skip advanced imaging if symptoms persist:

• Clinical examination alone has only 42-52% concordance with final diagnosis in acute shoulder trauma 2
• MRI reveals abnormalities in nearly all cases (85% in one study) when radiographs are normal but symptoms persist 2

Evidence Quality Note

The 2025 ACR Appropriateness Criteria represents the most current, highest-quality guideline evidence for this clinical scenario. 1 These guidelines consistently recommend MRI without IV contrast as the next appropriate imaging study when radiographs are normal but symptoms persist, with ratings of 7-9 (usually appropriate) across multiple clinical variants. 1