2018 - Donna Magid, M.D., M.Ed.

Shoulder for Pragmatists


“Shoulder’ is actually several joints including glenohumeral (GH), acromioclavicular (AC), sternoclavicular (SC), and scapulothoracic articulations. Specify to which you are referring! Clinicians usually mean ‘GH’ when they say ‘Shoulder’—but not always.

GH Joint: shallow ball-and-socket, head larger than glenoid. Allows enormous range of motion but at the cost of stability.

  • Fibrocartilaginous labrum deepens the glenoid ‘socket’, incrase contact area ~50%.
  • Rotator cuff (RC), capsule, cohesive/adhesive forces, help hold head against glenoid.
  • Multiple tissue stabilizer components: Coracoclavicular ligament is heavy ligament anchoring distal clavicle to scapula, bony acromial arch overhangs GH joint, with RC further preventing cephalad migration of the head.

Rotator cuff: supra and infraspinatous, subscapularis, teres minor

AC Joint: minimally mobile articulation transmitting forces, upper extremity (UE) ←→axial skeleton.

SC Joint: often not included on ‘shoulder’ radiographs. Only TRUE link of UE to axial skeleton; stabilizer for throwing/pushing motions. Never well-seen on radigraphs; may need CT (preferable 'Cephalo-caudally limited to area of interest" ie very few slices).

Scapulothoracic Articulation is actually muscle of chest wall, stabilizing and modifying scapula during complex range of motion (ROM). Rarely the focus of radiography. Scapula (medial 2/3s) never well-seen on radiographs.


Positioning texts show more views for the shoulder (primarily GH) than any other joint, reflecting its extreme mobility. In reality, traumatized patients are hypersensitive to motion and pressure. Most common standard views in Emergency Dept ( vs. outpt. Sports Medicine Clinic):

  • AP: scapula parallel to image plane, beam perpendicular to coracoid. Usually 2 APs:
  •   EXT. Rotation (of humerus): true anatomic AP prox. humerus, shows tuberosity
  •   INT. Rotation ("  "): lateral of humerus (‘light bulb’, bulbous shape,no tuberosity seen). 
  • Subacromial space should be 9 mm or more; if wildly different on one of 2 or 3 views say "Subacromial space 6 mm on internal rotation, not confirmed on ext. rotation..."  Assess such images for huge positional differences, such as cephalo-caudal beam angle changes between views. 
  • Subacromial region and perimeter of humeral head -- look for focal calcifications, distinct, lumpy, mature, rounded, cloudy, streaky, or otherwise, which can represent calcific tendonitis

There is no such thing as a true ‘lateral shoulder’ (massive superimposition) therefore alternatives:

  • AXILLARY ‘worm’s eye’ or ‘bird’s eye’ abduction view, for GH margins. “Coracoid points anteriorly” to get oriented.IMHO, best additional view of GH joint
  • Y view lateral scapula, oblique pt., arms at side: humeral head centered in “Y’ (Reverse Grashy similar, arm flexed over chest or back). Shows GH subluxation, not much else (IMHO)
  • Transthoracic lateral if cannot abduct for axillary (usually limited use; superimposition, obesity limit quality). 
  • (Many others: Grashey, coracoids, scapular, rolled film, West Point, etc—not common in EMed)
  • In Ortho Clinics many reqs will note "McFarland", "Zikria", "Dixit", "Shafiq" series, etc.-- these are the specific combination of views preferred by each of the named clinician.
  • If very limited exam-- often non-Orthopaedists request 2 views only-- make sure to note "2 views only, limited exam" or  "No definite abnormality on these views" or "Limited exam, if indicated axillary view may better visualize the area of interest..." or "AC joint not well seen on these views".

Figure 1. Shoulder Views and Dislocation

GH DISLOCATION (do NOT say ‘shoulder dislocation”; that is layperson’s term) = most common injury; described and illustrated (Fig. 2 Kochner technique) in the Eber medical papyrus 3000 BCE, and by Hippocrates.

  • 90% of patients who were < 20 y.o. at first dislocation will recur
  • Only 14% of GH disloc. are > 40; ie,  older pts.fracture instead of disloc. Increases with age

Figure 2. Kochner Technique

ANTERIOR DISLOCATION: 95% of GH disloactions (subcoracoid, subglenoid variants)

  • Head may impact under inferior glenoid palpable anteriorly in most; impacts/interlocks
  • HILL SACHS sign posterior-lateral head and corresponding BANKHART impaction lesion inferior glenoid
  • Inferior vector of displacement augments radiographic visibility
  • Older pts: more likely to have associated fxs, check post-reduction
  • All pts: clinicians must document neurovascular status pre/post reduction

POSTERIOR DISLOCATION: rare, 2-4% of GH dislocations

  • 50% missed at initial exam (“flat’ shoulder—check for symmetry, but posterior disloc. can be bilateral)
  • Takes far more force: seizure, electrical shock, ECT w/o relaxants. Axial load to adducted internally rotated shoulder; sudden contraction internal rotators which are 2x as powerful as external rotators.
  • Reverse Hill-Sachs = impaction of anterior humeral head against posterior glenoid.
  • Trough sign: subchondral C-shaped head line paralleling articular surface
  • Head may overlap glenoid fossa, normal ‘C’ of apposed articular surfaces (the rim) gone; far less likely to displace inferiorly and far MORE likely to be missed clinically/radiographically.
  • Fixed internal rotation.

INFERIOR (LUXATIO ERECTA): very rare, axial force to overhead arm or forced hyperabduction (motorcycle with high handlebars, construction worker). Inferior capsule tears, humeral head goes inferiorly, arm locks overhead—pt. arrives abducted with arm flexed over head. HIGH INCIDENCE of brachial plexus, other nerve injury.

PSEUDOSUBLUXATION: widening of the GH joint (widened ‘C’ formed by parallel margins)

  • Head drifts out of glenoid secondary to capsule distention with fluid, hemarthrosis (most common), chronically stretched capsule or muscle, hemiplegia (stroke) and marked muscle/tissue laxity, nv/brachial plexus injury.
  • Axial view will show GH is NOT subluxed. Important to think of pseudosubluxation or hemarthrosis to prevent (futile, painful, harmful) attempts to ‘relocate’ a widened pseudosubluxed GH joint.
OSTEOARTHROSIS: May involve GH or AC joints. GH cartilage loss often well-confirmed on axial view.  Asymmetrically narrowed GH space implies cartilage loss. as do marginal osteophytes head-neck and/or glenoid margins. AC joint can also narrow and/or develope osteophytes or reactive changes.  Large inferior osteophytes at AC joint can impinge subjacent soft tissue (RC) during range of motion (ROM).
ARTHROPLASTY or GH joint replacement can be a hemi-arthroplasty (humeral side only), a total shoulder arthroplasty (TSA, both sides of GH joint) or a reverse TSA (humeral component holds the cup socket, glenoid holds the ball-- usually implies previous revision of a more comventinal TSA).  Look for older images- mention if drains and staples removed since last exam, if alignment acceptible, if metal-bone interfaces less than 1 mm and unchanged (ie 'no evidence motion or loosening').  In a totally unremarkable and unchanged post-op exam, "Unchanged and unremarkable compared to last exam 1/3/18" is fine; there are many routine post-op check-ups foloowing arthroplasty. 
Reading the Orthopaedists' notes (as well as older Imaging reports if from the MSK Section) will greatly expand your comprehension and horizons. 
As always, anything on image is our responsibility:
BICEPS tendon calcification: small rounded mature radiodensity superimposing proximal diametaphyseal humerus (see Normal Variants text).  May project medial, lateral, or over bone depending on position.
LUNG radiodensity or possible finding should detonate search for older chest studies (radiograph, CT), or scoliosis, T spine,or other shoulder images showing this area.  Try to document don't-worries-- "Unchanged from previous shoulder exam 6 yrs ago", "Described as granuloma on CT 3 years ago", "Very likely calcified granuloma although no comparison images availible"
If more worrisome, mass-like, irregular, in pt. with hx. of neoplasm, etc, suggest F/U using Fleischner Thoracic criteria guidelines, and URGENT MACRO it to the referring clinician. Key image always helpful.
Should you suspect you have glimpsed edge of aneurysm, PTX, apical plural thickening, soft tissue anomaly---pursue and comment if indicated.
RIB lesions-- may be clearly old trauma, unsuspected more acute trauma, or mets/neoplasm etc.  Again seek older imaging and clinical hx.documentation to assess known/unknown/worry/don't-worry spectrum, make a key image, and notify referring clinician if indicated.
Note mastectomy/chest wall clips if seen.
Describe any surgical material-- refer to old notes and do not be more precise than your actual fund of knowledge allows ("Hardware" or "Surgical material subchondral glenoid" preferred to often- erroneous, seemingly more sophisticated naming of hardware -- clincians will not be happy with errors in patient records).


2018 - Donna Magid, M.D., M.Ed.