Shoulder Radiography 3

1 Shoulder Radiography
S. Bianchi, N. Prato, C. Martinoli, L. E. Derchi

CONTENTS tendon calcifications), presence of localised altera-

tions of the articular cartilages, or of intraarticular
1.1 Examination Technique and Shoulder Views 3 and bursal effusion, and the inability to image the
1.1.1 AP View of the Shoulder Region 3 glenoid labrum and the bone marrow. As in many
1.1.2 AP Tangential View 4
1.1.3 Outlet View 5 other joints, however, SR is the first technique to be
1.1.4 Leclercq Test 5 used if an imaging modality is needed; others are
1.1.5 Bicipital Groove View 6 then performed on the basis of the clinical findings,
1.1.6 Axillary View 6 the structure to be evaluated and the results of SR.
1.1.7 Apical Oblique View 8 The aims of this chapter are to illustrate the cur-
1.1.8 Bernageau View 10
1.1.9 Stryker View 10 rent techniques of shoulder SR, including a survey
1.1.10 West Point View 10 of the different views, to describe the normal radio-
1.1.11 Acromioclavicular Views 11 graphic anatomy and to propose a practical approach
1.1.12 Sternoclavicular Views 11 to the choice of views to be obtained in different clini-
1.2 Clinical Application 11 cal situations.
1.2.1 Acute Post-traumatic Examination 12
1.2.2 Standard Examination 12
References 12

1.1
Although in recent years US, CT and MRI, together Examination Technique and Shoulder Views
with CT and MR arthrography, have gained wide
popularity in the evaluation of shoulder diseases, 1.1.1
standard radiography (SR) still remains the most AP View of the Shoulder Region
often performed imaging examination of this ana-
tomical region. The main advantages of SR are the The anteroposterior (AP) view (Fig. 1.1) is the most
easy accessibility, low cost, panoramic view and short commonly obtained view of the shoulder and the
time of examination. Additionally, the basic findings easiest to perform by the technologist, particularly
provided by radiography are well known and familiar in severely traumatised patients. The patient can be
both to radiologists and clinicians. examined either standing or supine with the trunk
Disadvantages of SR include the low capability not rotated. The X-ray beam is centred medial to
to assess soft tissues lesions (with the exclusion of the glenohumeral joint. A large cassette (30×40 cm)
allows visualisation of the scapula, the proximal por-
tion of the humerus and the lateral chest wall. Since
S. Bianchi, MD the scapula is not oriented in a true coronal plane,
Division of Radiodiagnosis and Interventional Radiology, but lies in a coronal oblique plane (40°), this view is
Hopital Cantonal Universitaire, 24 rue Micheli-du-Crest, 1211 not perpendicular to the scapula and is not tangential
Geneva, Switzerland
N. Prato, MD to the glenohumeral joint space. Then, the obliquity
Division of Radiodiagnosis, Ospedale San Carlo, Piazzale Gia- of the beam with respect to the axis of the scapula
nasso, 16158 Genoa, Italy results in an elliptical appearance of the glenoid
C. Martinoli, MD cavity. The anterior rim of the glenoid fossa projects
Istituto di Radiologia, Università di Genova, Largo R Benzi 8, medially while the posterior rim projects laterally.
16100 Genoa, Italy
L. E. Derchi, MD Since the humeral head overlies the glenoid, assess-
Istituto di Radiologia, Università di Genova, Largo R Benzi 8, ment of the glenohumeral space is suboptimal in this
16100 Genoa, Italy view. The arm is usually held in neutral rotation.
4 S. Bianchi et al.

a b

Fig. 1.1a, b. AP view of the shoulder region and examination technique with corresponding radiographs. The radiograph is
obtained utilising a horizontal beam and without rotation of the trunk of the patient. a Since the beam is not tangential to the
glenohumeral joint, the glenoid cavity appears as an ellipse that superposes to the medial aspect of the humeral head. Assess-
ment of the glenohumeral space is suboptimal. The arm is in neutral rotation. Employment of a large cassette allows good
visualisation of the scapula, proximal portion of the humerus and of the chest wall. b Enlargement of (a) shows the glenoid
fossa as an elliptical structure. White arrow, posterior glenoid rim; black arrow, anterior glenoid rim

1.1.2 tion visualises the lesser tuberosity (LT) in profile.

AP Tangential View The LT appears as a triangular structure seen in
the most medial aspect of the head that projects
When obtaining an AP tangential view (Fig. 1.2) (also over the glenoid cavity. Due to the larger size of the
known as the subacromial view), the X-ray beam is greater tuberosity (GT) the anterior two thirds of it
directed tangential to the glenohumeral joint and to are imaged face-on while the posterior third is seen
the subacromial space. The patient is standing in a in profile. In neutral rotation the LT is visualised „en
40° posterior oblique position with the shoulder to face“ while the middle portion of the GT is seen „en
be examined in contact with the examining table. In profile“. External rotation allows profile visualisation
this position the scapula lies parallel to the cassette of the LT and of the anterior portion of the GT. The
and allows an optimal tangential view of the gleno- biceps sulcus lies between the two tuberosities and
humeral joint. The articular surface of the glenoid can be examined in profile both in maximal external
cavity is seen in profile and, in normal conditions, and internal rotation and „en face“ in neutral rota-
no overlap of the glenoid cavity and humeral head tion. Due to tangential orientation of the beam, the
is observed. Additional craniocaudal angulation anterior and posterior rims of the glenoid fossa are
(10–20°) of the beam leads to excellent visualisa- superimposed. The glenohumeral joint space width
tion of the subacromial space. Since the orientation can be accurately evaluated and reflects the thick-
of the scapula, as well as the obliquity of the acro- ness of both the humeral and glenoid cartilages. A
mial arch, can vary in patients, fluoroscopic control thin curvilinear radiolucency extending from the
can be used to achieve accurate positioning of the undersurface of the acromion to the GT and located
patient and correct tilting of the X-ray beam. Three deep to the deltoid muscle can be frequently imaged
radiographs are obtained with the arm in different in AP projection, especially if this is obtained with
rotations (neutral, internal and external). After each internal rotation of the arm (Mitchell et al. 1988).
rotation of the humerus the obliquity of the patient, The finding corresponds to the fat located on either
as well as the correct visualisation of the subacromial side of the subacromial synovial bursa. A radiolucent
space, must be checked since changes in the rotation area in the lateral aspect of humeral head is some-
of the arm are frequently associated with changes times apparent in the AP views. This finding, known
in the position of the patient. The coracoid process as „the humeral pseudocyst“, is a normal variant and
overlies the medial aspect of the humeral head. Due must be differentiated from different diseases such
to the orientation of the beam, the inferior surface of as a chondroblastoma, a giant cell tumor or a metas-
the acromion appears as a regular cortical line. The tasis (Helms 1978). In an attempt to elucidate the
different rotations of the arm allow good evaluation nature of the pseudocyst, Resnick and Cone (1983)
of the humeral head structures. The internal rota- examined a large number of macerated specimens
Shoulder Radiography 5

a b c

d e f

Fig. 1.2a–f. AP tangential view and examination technique with corresponding radiographs. Radiographs obtained with (a) neutral,
(b) internal and (c) external rotation of the arm. The views allow optimal assessment of the glenohumeral joint and subacromial
space. Note superposition of the anterior and posterior glenoid rim (arrows) and the sharply defined cortical line corresponding
to the inferior surface of the acromion (small arrow). The coracoid process overly the medial aspect of the humeral head (Co).
The different rotations of the arm lead to en face and en profile view of the greater tuberosity (GT) (asterisk) and lesser tuberosity
(small asterisk). d Peribursal fat. A thin curvilinear radiolucency (arrows) extending from the undersurface of the acromion to
the GT corresponds to the fat located at each side of the subacromiodeltoideal bursa. e, f Rotator cuff calcifications. External (e)
and internal (f) rotation projections disclose calcifications inside the supraspinatus (black arrow) and infraspinatus (white arrow)
tendons. With internal rotation the calcification located inside the posterior infraspinatus tendon moves laterally

and concluded that the image is due to the difference apparent in young individuals. In the rare cases in
of density between the abundant spongiosa in the which the image is doubtful, examination of the
medial metaphysis and the more porous spongiosa in contralateral shoulder performed with the identical
the GT region, laterally. The more abundant metaphy- angulation of the X-ray beam and the same rotation
seal spongiosa explains why the pseudocyst is more of the arm, shows a similar finding.
6 S. Bianchi et al.

1.1.3 humeral head and the lower surface of the acromion

Outlet View decreases by more than 2 mm as compared to the
reference radiograph (Prato et al. 1991). A similar
This view (Fig. 1.3 is also known as the Y, mercedes- projection, with an abduction of 90° or to the maxi-
benz or scapular axial view. The patient is standing, mum extent, has been described more recently in the
positioned in an anterior oblique position with the English radiological literature (Bloom 1991). In posi-
anterior aspect of the examined shoulder in contact tive tests, the superior displacement of the humeral
with the cassette. The arm is in neutral rotation. The head can be explained by the lack of action of the
beam, centred on the posterior aspect of the shoul- supraspinatus tendon, which normally depresses the
der, has a slight craniocaudal inclination (10°) tan- humeral head and fixes it against the glenoid to pro-
gential to the scapula. The correct positioning of the vide a fulcrum for abduction of the arm (van Ling
patient and orientation of the beam can be obtained and Mulder 1963).
by performing the examination under fluoroscopic
control. This makes it possible to tilt the X-ray beam
and to rotate the patient in such a way as to reach 1.1.5
optimal tangential view of both the subacromial Bicipital Groove View
space and the scapula. In severe trauma, an anterior
oblique position of the horizontal patient with the This view is obtained with the patient supine and the
beam centred on the anterior aspect of the shoul- x-ray beam directed cranially with a medial angu-
der can also be obtained, although magnification of lation of 15–25° (Fig. 1.5). The projection allows a
the image, due to the increased distance between nearly tangential view of the anterior face of the
the shoulder and the cassette, is evident (De Smet humeral head (Cone et al. 1983). The bicipital sulcus,
1980b). The scapula is imaged as a Y, formed by the GT and LT are demonstrated. Erosions of the groove
coracoid (anteriorly), the body of the scapula (infe- as well as spurs are imaged. Due to the relatively poor
riorly) and the acromion (posteriorly). In normal quality of the radiographic findings, when accurate
conditions the humeral head appears centred on evaluation of the bicipital groove is warranted, CT
the Y. The subacromial space and the scapulotho- scan is nowadays the technique of choice.
racic spaces are seen tangentially. The LT is imaged
between the scapula and the chest wall. The GT is
seen „en face“. 1.1.6
The acromion is well visualised in this view. Axillary View
Its shape can be assessed and classified into three
main types: flat, curved and hooked (Bigliani and The axillary projection provides a view orthogonal
Morrison 1986). More recently, the anterior tilt of to that obtained with the AP view (De Smet 1980a)
the acromion has been analyzed as an additional (Fig. 1.6). The view can be obtained in the erect or
factor affecting anterior impingement syndrome and horizontal positions, depending on the condition
secondary rotator cuff tears (Prato et al. 1998). of the patient. Different techniques can be utilised
(Kreel and Paris 1979; Neer 1990). A curvilinear
cassette can be placed under the patient’s axilla and
1.1.4 the beam can be oriented on the upper face of the
Leclercq Test shoulder. Alternatively, the beam can also be centred
to the axilla and the cassette placed over the shoulder.
The Leclercq test was introduced in 1950 as a radio- An abduction of at least 30–40° is usually necessary
logical indirect evaluation of the supraspinatus to obtain diagnostic radiographs. The main utility
tendon (Fig. 1.4) (Leclercq 1950). The patient is of this view is its possibility to image the anterior
standing in a slight posterior oblique position. First, and posterior aspects of the glenoid fossa and to
a reference radiograph is obtained with the arm assess glenohumeral relations. The projection can
hanging against the patient’s side. Then, to obtain be obtained with external or internal rotation of the
an actively resisted abduction, the patient is asked to arm, although appreciation of different humeral head
apply pressure to the handle of the radiographic table faces can be easily obtained by the AP projection
with the distal part of the forearm. The manoeuvre performed in different rotation. The anterior part of
is performed at 30° of abduction. The test is consid- the coracoid process as well as the acromioclavicular
ered to be positive when the distance between the joint are well imaged.
Shoulder Radiography 7

Fig. 1.3a–d. Outlet view and examination technique

with corresponding radiographs. a The scapula is
imaged in the axial plane. The beam is tangential to
the scapulothoracic joint and the subacromial space
allowing their optimal evaluation. The humeral head
is centred on the Y formed by the coracoid, the body
of the scapula and the acromion. Acr, acromion; Cl,
lateral epiphysis of the clavicle; Co, coracoid; aster-
isk, small tuberosity. b–d Acromion morphology.
bType 1: flat acromion; c type 2: curved acromion;
d type 3: hooked acromion. e Rotator cuff calcifi-
cations. Calcifications of the supraspinatus (black
arrow) and infraspinatus (white arrow) tendons
are evident

b c

d e
8 S. Bianchi et al.

a b

Fig. 1.4a–d. Leclercq test.

Drawing showing the exami-
nation technique and the
pathogenesis and corre-
sponding radiographs.
a Negative test. b Positive
test. In (b) note the supe-
rior displacement of the
humerus due to the lack of
fixation of the humeral head
against the glenoid.
c AP view with the arm
hanging in neutral rotation
(d). AP view obtained during
resisted abduction (20°) of c d
the arm. Positive test

1.1.7
Apical Oblique View

In order to obtain this view, the patient is exam-

ined, either standing or horizontal, in a posterior
oblique position (45°) relative to the X-ray tube
(Fig. 1.7. This can be easily obtained by rotating the
unexamined shoulder away from the cassette. The
X-ray beam is tilted at approximately 45° of caudal
angulation and centred on the glenohumeral space
(Garth et al. 1984). Although the apical oblique
projection is not a true axial view like the axil-
lary view, it is useful in estimating the relationship
between the humeral head and the glenoid fossa. In
normal cases the humeral head is at the same level
of the glenoid fossa. Because of the cranio-caudal
and anteroposterior direction of the incident beam,
displacement of the head in the axial plane can be
diagnosed. A posteriorly dislocated humeral head
projects superior to the glenoid cavity, while in ante-
rior dislocation it projects inferior to it (Sloth and
Just 1989). This projection effectively images the
anteroinferior aspect of the anterior glenoid rim as
Fig. 1.5. Bicipital groove view and examination technique with
corresponding radiographs. Radiograph shows the greater well as the posterocranial segment of the humeral
(large asterisk) and lesser (small asterisk) tuberosities as well head. Both areas are commonly injured in anterior
as the bicipital groove dislocation of the shoulder.
Shoulder Radiography 9

a b

c d

Fig. 1.6a–d. Axillary view. Drawing showing the examination technique and corresponding radiographs. a, b Internal (a) and
external (b) rotation axillary views allow tangential demonstration of the anterior and posterior aspect of the glenoid fossa and
scapular neck. Accurate assessment of the glenohumeral relations and of the acromioclavicular joint is also obtained. White
arrow = posterior glenoid rim, black arrow = anterior glenoid rim. Acr, acromion; Cl, lateral epiphysis of the clavicle; Co, cora-
coid. c, d Axillary views in a patient with voluntary shoulder instability obtained before (c) and after (d) dislocation confirm
posterior subluxation of the humeral head. Gl, glenoid cavity; HH, humeral head

a b

Fig. 1.7a, b. Apical oblique view and examination technique with corresponding radiographs. a Caudal angulation of the X-ray
beam results in an elongated appearance of the humeral head. The clavicle appears shorter because of the posterior oblique
position of the patients. The posterosuperior aspect of the humeral head and the inferior aspect of the anterior glenoid rim
are well visualised. Co, coracoid process; Cl, clavicle. b In a patient with posterior dislocation of the shoulder note superior
displacement of the humerus and superposition of glenoid fossa and humeral head
10 S. Bianchi et al.

1.1.8 1.1.9
Bernageau View Stryker View

The Bernageau view was introduced in 1966 to obtain This projection, also known as the „notch“ view, was
an optimal visualisation of the anteroinferior segment reported in 1959 as a useful means for detecting
of the glenoid rim in patients with anterior instabil- humeral head fractures associated with anterior dislo-
ity (Bernageau et al. 1966) (Fig. 1.8). Because of the cation of the shoulder (Hall et al. 1959) (Fig. 1.9. The
curvilinear shape of the rim, its inferior portion super- patient is supine with his/her arm flexed and the palm
imposes on the superior segment when imaged in the placed on the top of the head. The beam is directed to
axillary view (that is tangential to the middle third). the coracoid process, 10° cephalad. This view is also
Since the inferior portion of the rim is more frequently performed in a standing patient. Furthermore, the
damaged in anterior shoulder dislocation, the authors view allows a good assessment of the AC joint.
introduced this projection to allow its true tangential
view and accurate assessment. The patient (standing
or seated) is examined in anterior oblique position 1.1.10
with the arm abducted at 135° and the hand resting on West Point View
the head. The beam is directed on the posterior aspect
of the shoulder. A 30° caudal tilt of the X-ray beam is The West Point view was introduced to evaluate bone
utilised. Optimal angulation of the beam and rotation changes secondary to anterior dislocations of the
of the patient can be obtained under fluoroscopic guide. shoulder (Rokous et al. 1972). The patient lies prone
Bilateral examination has been suggested for evaluation with the arm abducted at 90° and the forearm hang-
of subtle changes (Bernageau and Patte 1984) ing over the lateral aspect of the table. The cassette

Fig. 1.8a, b. Bernageau view and examination technique with

corresponding radiographs. a The inferior segment of anterior
glenoid rim appears as a triangular structure (black arrows),
the superior segment appears as a cortical line (white arrow).
Acr, acromion; Cl, clavicle. b In a patient with posterior insta-
bility of the shoulder the Bernageau projection shows hypo-
plasia of the posterior rim of the glenoid (black arrow)

a b
Shoulder Radiography 11

Fig. 1.9. Stryker view and examination technique with corresponding radiographs. Radiograph shows the postero-superior por-
tion of the humeral head (white arrow). The coracoid including its base is well demonstrated. Cor, coracoid process

is positioned on the superior aspect of the shoulder, tion of AC instability, particularly in patients with
perpendicular to the table. The ray beam is directed mild subluxation. Imaging of both joints in a single
to the axilla and is angled 25° in a cephalad direction cassette provides comparison with the contralateral
and 25° in a lateral to medial direction. joint and allows demonstration of subtle findings.

1.1.11 1.1.12
AC Views Sternoclavicular Views

The AC joint is imaged in almost all the shoulder Although different views have been described to
views but superimposition of other structures usu- evaluate the sternoclavicular joint, all lead to poor
ally limits the correct interpretation of the radio- results because of the impossibility of imaging the
logical findings (Fig. 1.10). Optimal visualisation of joint in the axial plane.
the joint can be obtained in an AP view with a 15°
cephalic tilt of the beam. Utilisation of equalisation
silicone filters is useful since they avoid peripheral
over-penetration and allow a better assessment of 1.2
both the AC joint and the subacromial space. Clinical Application
Stress AP radiographs are performed by asking
the patient to hold a 5 kg weight in both hands. The A radiograph of the shoulder can be performed basi-
traction on the upper arms allows good visualisa- cally in two situations: As a part of a radiographic

Fig. 1.10. AC view and examination technique with corresponding radiographs. Cranial oriented X-ray beam shows the acromio-
clavicular joint. Acr, acromion; Cl, clavicle; Cor, coracoid process
12 S. Bianchi et al.

evaluation of an acute post-traumatic patient, to rule coracoacromial ligament. In patients with a history of
out the possibility of a fracture or a dislocation, or previous shoulder instability, the Bernageau projec-
as a part of an imaging evaluation when a shoulder tion allows optimal visualisation of the anteroinferior
problem is clinically suspected. segment of the glenoid rim. The Hill-Sachs lesion can
be well imaged in a variety of views including the
apical oblique view, the AP view obtained with maxi-
1.2.1 mal internal rotation, the Stryker view and the West
Acute Post-traumatic Examination Point view (Sartoris and Resnick 1995).

The most common questions to be answered in the Acknowledgements. The authors thank Miss. Mariella
radiographic evaluation of the acute patient are two: Ferrando RDT and Mr. Alessandro Franconeri RDT
Is there a fracture? Is there a dislocation? In this clini- for their help in preparing the schematic drawings
cal setting, the smaller number of views in the most and the illustrations
comfortable patient positions must be obtained.
If the patient cannot stand up and lies supine, the
shoulder can be imaged in the anteroposterior view
with a 35×43 cm cassette. The use of a wider cassette References
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