Shoulder Joint Chronic Pain: 3-View Radiograph Recommendation
Yes, you need at least a 3-view radiograph series for chronic shoulder pain, which should include anteroposterior (AP) views in internal and external rotation plus an axillary or scapula-Y view. 1
Standard Radiographic Protocol for Chronic Shoulder Pain
The American College of Radiology explicitly states that all shoulder radiographic studies for trauma should include at minimum 3 views, with 2 being orthogonal 1. While this guideline specifically addresses acute trauma, the same principle applies to chronic pain evaluation as the initial screening modality 1.
Required Views:
- AP view in internal rotation 1
- AP view in external rotation 1
- Axillary lateral view OR scapular Y view 1
The axillary or scapular Y view is vital because acromioclavicular and glenohumeral joint pathology can be completely missed or misclassified on AP views alone 1, 2. This is a common pitfall that leads to missed diagnoses 2.
Why This Matters for Chronic Pain
Radiographs serve as the preferred initial diagnostic modality for shoulder pain because they effectively demonstrate 1:
- Joint alignment abnormalities
- Degenerative changes and arthritis
- Calcific tendinitis
- Bone erosions
- Acromioclavicular joint pathology
Perform radiographs upright, not supine, as shoulder malalignment can be significantly underrepresented on supine imaging 1, 2. This technical detail is frequently overlooked but critically important 2.
When Radiographs Are Not Enough
If your 3-view radiographs are noncontributory (normal or indeterminate), the next imaging step depends on your clinical suspicion 1, 3:
For Suspected Rotator Cuff Pathology:
- Ultrasound is generally preferred over MRI for chronic rotator cuff pain evaluation 3
- Ultrasound is comparable to MRI for full-thickness tears but less accurate for partial tears 1, 4
For Suspected Labral Tears or Instability:
- MR arthrography is rated 9/9 (usually appropriate) by the American College of Radiology 1, 2
- MR arthrography with abducted and externally rotated images is most accurate 3
- Standard MRI without contrast is rated 7/9 (also usually appropriate) if you have optimized imaging equipment 1
For Suspected Bursitis or Biceps Tenosynovitis:
Critical Pitfall to Avoid
Never rely on AP views alone 2. The single most common error in shoulder imaging is obtaining only frontal projections, which will miss posterior dislocations, AC joint separations, and subtle malalignment 1, 2. The orthogonal view (axillary or scapular Y) is not optional—it's essential 1.