Initial Imaging for Shoulder and Upper Back Pain
Plain radiography is the appropriate initial imaging test for shoulder pain and upper back pain, consisting of a minimum three-view series: anteroposterior (AP) views in internal and external rotation plus an axillary or scapular Y view. 1, 2, 3
Why Radiography First
- Radiography is a safe, fast, low-cost imaging modality that effectively demonstrates many forms of shoulder pathology including fractures, dislocations, arthritis, and calcific tendinitis 1, 4
- Plain radiographs provide excellent delineation of bony anatomy to assess for fractures and proper shoulder alignment, which are the primary concerns requiring immediate management 3
- Radiography should be the first imaging study performed in essentially all cases of shoulder pain, regardless of whether the presentation is acute or chronic 4, 5, 6
Required Radiographic Views
The standard shoulder trauma series must include at least three views 1, 2, 3:
- AP view in internal rotation 2, 3
- AP view in external rotation 2, 3
- Axillary or scapular Y view 1, 2, 3
Critical Technical Point
- Perform radiographs upright rather than supine whenever the patient's condition permits, as shoulder malalignment can be underrepresented on supine imaging 3
- The axillary lateral or scapular Y view is absolutely vital because glenohumeral dislocations are routinely misclassified on AP views alone—posterior dislocations are missed in over 60% of cases without proper orthogonal views 2
When to Consider Advanced Imaging
After obtaining initial radiographs, advanced imaging may be indicated based on findings:
If Radiographs Are Normal But Clinical Suspicion Remains:
- MRI without contrast is indicated for suspected rotator cuff tears, labral injuries, or soft tissue pathology 1, 2, 7
- Ultrasound can be equivalent to MRI for evaluating rotator cuff tears and biceps tenosynovitis in experienced hands 1
If Radiographs Show Fractures:
- CT without contrast is reserved for better characterizing complex fracture patterns (especially scapular or proximal humerus fractures) when surgical planning is needed 2, 3
If Vascular Compromise Is Suspected:
- CT angiography is the preferred examination if vascular compromise is suspected following shoulder trauma, particularly with proximal humeral fractures where axillary artery injury can occur 2, 3
Common Pitfalls to Avoid
- Never attempt reduction of a suspected dislocation without radiographic confirmation, as this could worsen fracture-dislocations 2
- Do not skip the axillary or scapular Y view—failure to obtain proper orthogonal views leads to missed diagnosis of dislocation, particularly posterior dislocations 2
- Do not order MRI or ultrasound before obtaining plain radiographs, as many patients are inappropriately referred without basic X-rays first 4
- Do not overlook associated injuries such as rotator cuff tears, which are more common in older patients with shoulder pathology 2