When is a shoulder x-ray (radiograph) recommended for a patient with suspected shoulder injury or persistent shoulder pain, considering their age, medical history, and specific symptoms?

Shoulder X-Ray Indications

Shoulder radiography should be obtained as the initial imaging modality for all patients presenting with acute shoulder pain (less than 2 weeks) or suspected shoulder trauma, regardless of age, to exclude fractures, dislocations, and other bony pathology before proceeding with any advanced imaging or treatment decisions. 1

Initial Radiographic Protocol

Standard Views Required

• Minimum three orthogonal views are mandatory for adequate evaluation: 1, 2

  • Anteroposterior (AP) view with humerus in neutral position
  • AP view with internal or external rotation
  • Axillary lateral view OR scapular Y view (both orthogonal to the AP projections)

• The axillary or scapular Y view is absolutely critical because glenohumeral and acromioclavicular dislocations are routinely misclassified on AP views alone, with posterior dislocations missed in over 60% of cases when proper orthogonal views are not obtained. 2

Specific Clinical Scenarios

For Acute Trauma (any mechanism of injury):

• Obtain radiographs immediately before attempting any reduction maneuvers, as failure to do so could worsen fracture-dislocations. 2
• A Grashey projection (30° posterior oblique) is recommended to properly profile the glenohumeral joint. 1
• Post-reduction radiographs are necessary to confirm successful reduction and identify fractures that may have been obscured by the dislocation. 2

For Suspected Instability or Dislocation:

• Axillary lateral view is essential but may be painful immediately post-dislocation; use caution as positioning could cause redislocation. 1
• Westpoint view (prone with arm abducted 90°) improves detection of bony Bankart lesions. 1
• Stryker notch view (supine, arm externally rotated and abducted, beam angled 10° cephalad) combined with AP internal rotation is sensitive for Hill-Sachs deformities. 1

For Suspected Impingement:

• Upright 30° angled caudad radiograph (Rockwood view) or suprascapular outlet view suffices for evaluating the anterior acromion. 1

When Radiographs Are Noncontributory

Age <35 Years with Suspected Labral Tear/Instability

• MR arthrography is the preferred next study (rated 9/9 appropriateness). 1
• MRI without contrast is acceptable with optimized equipment (rated 7/9). 1
• CT arthrography only if MRI is contraindicated (rated 5/9). 1

Acute Nonlocalized Traumatic Pain with Normal Radiographs

• Noncontrast MRI is the preferred advanced imaging because acute intra-articular pathology typically produces significant joint effusion that allows assessment of soft-tissue structures without contrast. 1
• MRI is superior for diagnosing bone marrow contusion, capsular tears, ligament tears, and physeal injuries in pediatric patients. 1
• Ultrasound can be considered as a screening tool in older patients (where rotator cuff tears are more common) but has limited usefulness for nonlocalized pain and is inferior to MRI for labroligamentous and osseous pathology. 1

Persistent Shoulder Pain (Chronic, Non-Traumatic)

• Radiography remains the appropriate initial screening modality for all causes of shoulder pain. 1
• If radiographs are normal and rotator cuff pathology or biceps tenosynovitis is suspected clinically, MRI without contrast is rated 9/9 appropriateness. 1

Critical Red Flags Requiring Immediate Attention

Before attributing bilateral shoulder pain to musculoskeletal causes:

• Obtain immediate ECG and cardiac biomarkers to exclude acute coronary syndrome, as bilateral shoulder pain with nausea can represent atypical angina, particularly in women and elderly patients. 3

Vascular assessment is critical in traumatic dislocations:

• Axillary artery injury can occur, especially with associated proximal humeral fractures. 2
• CT angiography is the preferred examination if vascular compromise is suspected. 2

Common Pitfalls to Avoid

• Never rely on AP views alone—this is the most common cause of missed posterior dislocations. 2
• Do not attempt reduction without radiographic confirmation of dislocation type and associated fractures. 2
• Do not delay reduction once imaging confirms dislocation, as this increases risk of neurovascular compromise. 2
• In older patients with dislocation, do not overlook associated rotator cuff tears, which are common and require evaluation. 2
• Plain radiographs detect only 0-12.5% of soft-tissue pathology in patients with shoulder pain; if clinical suspicion remains high despite normal radiographs, proceed directly to MRI rather than relying on ultrasound. 4, 5