How to Order a Right Shoulder X-Ray for Anterior Shoulder Pain
Order a minimum 3-view right shoulder radiographic series performed upright, including AP views in both internal and external rotation plus an axillary or scapular Y view—never rely on AP views alone as they will miss critical pathology. 1
Standard Radiographic Protocol
The American College of Radiology mandates at least 3 views with 2 being orthogonal for all shoulder radiographic studies. 1 This applies universally to both acute traumatic and chronic shoulder pain evaluation. 2, 1
Required Views for Anterior Shoulder Pain
- AP view in internal rotation – essential baseline view for detecting fractures, joint alignment, and calcific tendinitis 1
- AP view in external rotation – provides complementary information about humeral head pathology and joint space 1
- Axillary lateral view OR scapular Y view – absolutely critical as the orthogonal view; acromioclavicular and glenohumeral joint pathology can be completely missed or misclassified on AP views alone 2, 1
Technical Specifications
- Perform radiographs upright, not supine – shoulder malalignment can be significantly underrepresented on supine imaging 2, 1
- The axillary lateral view may be painful for patients with acute injury, but a modified technique with the patient standing upright and bending forward with 30-45 degrees craniocaudal tube angulation can reduce discomfort while maintaining diagnostic quality 3
- If the axillary view is too painful or technically difficult, the scapular Y view serves as an acceptable alternative 2
Why This Specific Protocol Matters
Radiographs serve as the preferred initial diagnostic modality for shoulder pain, effectively demonstrating joint alignment abnormalities, calcific tendinitis, bone erosions, and acromioclavicular joint pathology. 1 The anteroposterior view alone detects approximately 88% of shoulder injuries, but the orthogonal views (axillary or apical oblique) uniquely identify an additional 15-20% of pathology including glenoid rim fractures, Hill-Sachs lesions, posterior dislocations, and soft tissue calcifications. 4, 5
Critical Pitfall to Avoid
Never order only AP views. 1 The American College of Radiology explicitly warns that relying on AP views alone will miss posterior dislocations, AC joint separations, and subtle malalignment—all of which are critical to diagnosis and management. 2, 1 In one series, 20 abnormalities were detected only on the apical oblique view, including 11 glenoid rim fractures and 7 Hill-Sachs lesions that would have been completely missed. 4
When Initial Radiographs Are Noncontributory
If the 3-view radiographic series is negative but clinical suspicion remains for anterior shoulder pain:
- For suspected rotator cuff pathology or biceps tenosynovitis: MRI without contrast and ultrasound are rated equivalently (9/9) by the American College of Radiology 2, 1
- For suspected labral tear or instability (particularly in patients under 35 years): MR arthrography is rated 9/9, with MRI without contrast rated 7/9 if optimized equipment is available 2, 1
- For suspected bursitis: MRI without contrast and ultrasound are equivalent first-line studies (both rated 9/9) 2, 6
The choice between MRI and ultrasound depends on local expertise availability, with ultrasound offering the advantage of potential therapeutic injection during the same encounter. 2