ACR logo

Appropriateness Criteria

Variant 1: Adult. Acute shoulder pain. Any etiology. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography shoulder Usually appropriate Strong ☢ <0.1 mSv 9 9 0 0 0 0 0 0 1 1 12
References Study Quality
9 (17692769) 3
11 (24124199) 3
10 (19166638) 3
12 (35813132) 2
7 (20206348) 4
US shoulder Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 9 0 1 0 2 1 1 0 0
References Study Quality
13 (20848574) 2
MR arthrography shoulder Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 2 0 0 0 1 0 0 0
MRI shoulder without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 2 0 0 0 1 0 0 0
MRI shoulder without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 1 0 0 1 0 0 1 0
Bone scan shoulder Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 13 0 1 0 0 0 0 0 0
CT shoulder with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 11 1 1 0 0 0 1 0 0
CT shoulder without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 11 2 0 0 0 0 1 0 0
CT shoulder without IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv 2 2 5 3 2 3 0 1 0 0 0
References Study Quality
6 (18029890) 2
7 (20206348) 4
8 (25231817) 3
9 (17692769) 3
CT arthrography shoulder Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 12 0 0 1 1 0 0 0 0
FDG-PET/CT skull base to mid-thigh Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 13 1 0 0 0 0 0 0 0
Variant 2: Adult. Acute shoulder pain. Suspect occult fracture. Radiographs negative or indeterminate. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI shoulder without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 2 1 5 3 3
References Study Quality
21 (24172671) 4
20 (19305272) 2
19 (21940587) 3
18 (24560469) 4
17 (34033918) 2
CT shoulder without IV contrast Usually appropriate Strong ☢☢☢ 1-10 mSv 9 9 0 0 0 0 0 1 4 0 9
References Study Quality
16 (17325929) 2
15 (26295635) 4
14 (32656034) 2
US shoulder Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 9 0 2 1 0 1 1 0 0
References Study Quality
17 (34033918) 2
MR arthrography shoulder Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 0 0 1 0 1 0 0 0
MRI shoulder without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 10 2 0 1 0 0 1 0 0
Bone scan shoulder Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 12 1 0 0 0 1 0 0 0
CT shoulder with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 11 1 1 0 0 0 1 0 0
CT shoulder without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 11 2 0 0 0 0 1 0 0
CT arthrography shoulder Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 13 0 0 0 0 0 1 0 0
FDG-PET/CT skull base to mid-thigh Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 13 0 1 0 0 0 0 0 0
Variant 3: Adult. Acute shoulder pain. Radiographs positive for proximal humerus, scapular, or clavicle fracture. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
CT shoulder without IV contrast Usually appropriate Strong ☢☢☢ 1-10 mSv 9 9 0 0 0 0 1 1 3 1 8
References Study Quality
25 (16054146) 2
24 (19724000) 4
23 (17169583) 4
22 (19836976) 3
16 (17325929) 2
12 (35813132) 2
7 (20206348) 4
MRI shoulder without IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 4 4 0 2 4 2 5 0 0 0 0
References Study Quality
15 (26295635) 4
19 (21940587) 3
26 (19685061) 4
US shoulder Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 1 0 1 1 0 0 0 0
MR arthrography shoulder Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 0 0 1 0 1 0 0 0
MRI shoulder without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 1 0 1 0 1 0 0 0
Bone scan shoulder Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 13 1 0 0 0 0 0 0 0
CT shoulder with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 11 1 1 0 0 1 0 0 0
CT shoulder without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 11 2 0 0 0 1 0 0 0
CT arthrography shoulder Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 13 0 0 0 1 0 0 0 0
FDG-PET/CT skull base to mid-thigh Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 13 0 1 0 0 0 0 0 0
Variant 4: Adult. Acute shoulder pain. History or physical examination consistent with dislocation or instability. Radiographs positive, negative, or indeterminate. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI shoulder without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 1 0 0 0 0 2 0 10
References Study Quality
29 (19556150) 2
33 (19098184) 3
31 (24060014) 3
MR arthrography shoulder May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 4 2 4 1 0 0 1 1 0
References Study Quality
32 (16244267) 3
31 (24060014) 3
CT shoulder without IV contrast May be appropriate (Disagreement) Expert Opinion ☢☢☢ 1-10 mSv 5 5 0 4 0 1 4 1 3 0 0
References Study Quality
8 (25231817) 3
30 (23716283) 3
28 (24318071) 2
27 (29119123) 2
29 (19556150) 2
US shoulder Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 1 0 0 1 1 0 0 0
MRI shoulder without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 1 0 0 1 0 1 0 0
Bone scan shoulder Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 13 0 1 0 0 0 0 0 0
CT shoulder with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 10 1 0 0 2 1 0 0 0
CT shoulder without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 11 1 1 1 0 0 0 0 0
CT arthrography shoulder Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 7 1 2 2 1 0 0 0 0
FDG-PET/CT skull base to mid-thigh Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 13 0 1 0 0 0 0 0 0
Variant 5: Adult. Acute shoulder pain. Physical examination consistent with labral tear. Radiographs negative or indeterminate. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MR arthrography shoulder Usually appropriate Moderate O 0 mSv O 0 mSv [ped] 9 9 1 0 0 1 1 2 0 2 7
References Study Quality
45 (35122144) Good
44 (29582141) Good
43 (27826700) Good
41 (24794570) 3
40 (20950767) 3
39 (23801390) 3
38 (17896393) 4
37 (21907516) 2
32 (16244267) 3
33 (19098184) 3
42 (22401678) 3
MRI shoulder without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 4 3 7
References Study Quality
47 (26779556) 3
46 (28604236) Good
44 (29582141) Good
31 (24060014) 3
33 (19098184) 3
CT arthrography shoulder Usually appropriate Strong ☢☢☢☢ 10-30 mSv 7 7 1 0 0 0 4 1 3 5 0
References Study Quality
36 (21074344) 2
29 (19556150) 2
34 (22358006) 2
35 (31541346) 2
US shoulder Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 1 1 0 1 0 0 0 0
MRI shoulder without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 1 0 0 1 0 1 0 0
Bone scan shoulder Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 13 1 0 0 0 0 0 0 0
CT shoulder with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 11 1 1 0 0 0 1 0 0
CT shoulder without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 11 1 1 0 0 1 0 0 0
CT shoulder without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 11 1 0 0 0 1 1 0 0
FDG-PET/CT skull base to mid-thigh Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 13 0 1 0 0 0 0 0 0
Variant 6: Adult. Acute shoulder pain. Physical examination consistent with rotator cuff tear. Radiographs negative or indeterminate. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US shoulder Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 0 0 5 6 3
References Study Quality
31 (24060014) 3
57 (15674840) 2
56 (18651142) 2
55 (30744304) 4
54 (17149764) 2
53 (19457838) M
52 (18449121) 3
51 (18160242) 3
50 (18591598) 2
49 (25677796) M
MRI shoulder without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 1 0 0 0 0 0 2 1 10
References Study Quality
29 (19556150) 2
31 (24060014) 3
49 (25677796) M
MR arthrography shoulder Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 5 2 2 3 0 0 0 0 1
References Study Quality
49 (25677796) M
48 (34939473) Good
31 (24060014) 3
MRI shoulder without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 1 0 1 0 0 0 1 0
Bone scan shoulder Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 13 1 0 0 0 0 0 0 0
CT shoulder with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 11 1 1 0 0 0 1 0 0
CT shoulder without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 11 1 1 0 0 0 1 0 0
CT shoulder without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 11 1 1 0 1 0 0 0 0
CT arthrography shoulder Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 8 2 1 2 0 0 0 0 0
FDG-PET/CT skull base to mid-thigh Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 13 0 1 0 0 0 0 0 0
Appendix Key

A more complete discussion of the items presented below can be found by accessing the supporting documents at the designated hyperlinks.

Appropriateness Category:The panel’s recommendation for a procedure based on the assessment of the risks and benefits of performing the procedure for the specified clinical scenario.

SOE: Strength of Evidence. The assessment of the amount and quality of evidence found in the peer reviewed medical literature for an appropriateness recommendation.

  • References: The citation number and PMID for the reference(s) associated with the recommendation.
  • Study Quality: The assessment of the quality of an individual reference based on the number of study quality elements described in the reference.

RRL: Relative Radiation Level. A population based assessment of the amount of radiation a typical patient may be exposed to during the specified procedure.

Rating: The final rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Median: The median rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Final tabulations: A histogram showing the number of panel members who rated the procedure as noted in the column heading (ie, 1, 2, 3, etc.).

Additional supporting documents about the AC methodology and processes can be found at www.acr.org/ac.