Shoulder Joint Chronic Pain: Radiograph Recommendations

Standard Radiographic Protocol for Chronic Shoulder Pain

• The American College of Radiology recommends a minimum of 3 views, with 2 being orthogonal, for shoulder radiographic studies, including anteroposterior (AP) views in internal and external rotation plus an axillary or scapula-Y view, for the evaluation of chronic shoulder pain 1, 2, 3
• The American College of Radiology explicitly states that all shoulder radiographic studies should include at minimum 3 views, with 2 being orthogonal, which applies to chronic pain evaluation as the initial screening modality 3, 1

Required Views

• The American College of Radiology recommends AP view in internal rotation for the evaluation of chronic shoulder pain 1, 2
• The American College of Radiology recommends AP view in external rotation for the evaluation of chronic shoulder pain 1, 2
• The American College of Radiology recommends an axillary lateral view or scapular Y view for the evaluation of chronic shoulder pain, as acromioclavicular and glenohumeral joint pathology can be completely missed or misclassified on AP views alone 1, 2, 4

Why This Matters for Chronic Pain

• Radiographs serve as the preferred initial diagnostic modality for shoulder pain, effectively demonstrating joint alignment abnormalities 3, 4, calcific tendinitis 1, bone erosions 2, and acromioclavicular joint pathology 4
• The American College of Radiology recommends performing radiographs upright, not supine, as shoulder malalignment can be significantly underrepresented on supine imaging 2, 4

When Radiographs Are Not Enough

• If 3-view radiographs are noncontributory, the next imaging step depends on clinical suspicion, with ultrasound generally preferred over MRI for chronic rotator cuff pain evaluation, and MR arthrography rated 9/9 for suspected labral tears or instability 2, 3, 4
• The American College of Radiology rates MR arthrography 9/9 for suspected labral tears or instability, and MRI without contrast 7/9 if optimized imaging equipment is available 3, 4
• The American College of Radiology rates MRI without contrast 9/9 for suspected bursitis or biceps tenosynovitis, with ultrasound equivalent to MRI for this specific indication 3

Critical Pitfall to Avoid

• The American College of Radiology warns against relying on AP views alone, as this can miss posterior dislocations, AC joint separations, and subtle malalignment, emphasizing the essential nature of the orthogonal view (axillary or scapular Y) 1, 2, 4