American College of Radiology
ACR Appropriateness Criteria®

Shoulder Pain-Atraumatic

Variant 1: Atraumatic shoulder pain. 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 ☢ <0.1 mSv 9 9 0 0 0 0 0 0 0 0 16
CT arthrography shoulder Usually not appropriate ☢☢☢☢ 10-30 mSv 1 1 15 0 1 0 0 0 0 0 0
CT shoulder with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 1 15 0 1 0 0 0 0 0 0
CT shoulder without IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 1 13 1 1 1 0 0 0 0 0
CT shoulder without and with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 1 16 0 0 0 0 0 0 0 0
X-ray arthrography shoulder Usually not appropriate ☢ <0.1 mSv 1 1 16 0 0 0 0 0 0 0 0
MR arthrography shoulder Usually not appropriate O 0 mSv O 0 mSv [ped] 1 1 14 0 1 0 1 0 0 0 0
MRI shoulder without IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 1 12 0 0 1 1 2 0 0 0
MRI shoulder without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 1 14 0 1 1 0 0 0 0 0
US shoulder Usually not appropriate O 0 mSv O 0 mSv [ped] 1 1 12 1 1 1 0 1 0 0 0
Variant 2: Atraumatic shoulder pain. Suspect rotator cuff disorders (tendinosis, tear, calcific tendinitis). Initial radiographs normal or inconclusive. 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 O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 0 3 13
US shoulder Usually appropriate O 0 mSv O 0 mSv [ped] 8 8 1 0 0 0 2 0 3 4 6
MR arthrography shoulder May be appropriate O 0 mSv O 0 mSv [ped] 6 6 0 0 2 0 6 5 2 0 1
CT arthrography shoulder May be appropriate ☢☢☢☢ 10-30 mSv 5 5 0 0 0 2 12 2 0 0 0
Radiography shoulder additional views Usually not appropriate ☢ <0.1 mSv 2 2 7 5 0 0 3 0 0 0 1
CT shoulder with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 1 15 1 0 0 0 0 0 0 0
CT shoulder without IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 1 10 1 1 0 2 1 1 0 0
CT shoulder without and with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 1 16 0 0 0 0 0 0 0 0
X-ray arthrography shoulder Usually not appropriate ☢ <0.1 mSv 1 1 9 1 0 4 1 0 1 0 0
MRI shoulder without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 1 14 0 1 0 1 0 0 0 0
Variant 3: Atraumatic shoulder pain. Suspect labral tear and instability. Initial radiographs normal or inconclusive. 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 O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 1 3 12
MRI shoulder without IV contrast Usually appropriate O 0 mSv O 0 mSv [ped] 8 8 1 0 0 0 2 1 4 4 4
CT arthrography shoulder May be appropriate ☢☢☢☢ 10-30 mSv 6 6 0 0 0 0 7 8 1 0 0
CT shoulder with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 1 15 1 0 0 0 0 0 0 0
CT shoulder without IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 1 14 0 1 0 0 0 1 0 0
CT shoulder without and with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 1 15 1 0 0 0 0 0 0 0
X-ray arthrography shoulder Usually not appropriate ☢ <0.1 mSv 1 1 14 1 0 0 0 1 0 0 0
MRI shoulder without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 1 14 0 2 0 0 0 0 0 0
US shoulder Usually not appropriate O 0 mSv O 0 mSv [ped] 1 1 10 1 1 2 2 0 0 0 0
Radiography shoulder additional views Usually not appropriate ☢ <0.1 mSv 1 1 9 4 0 1 0 1 1 0 0
Variant 4: Atraumatic shoulder pain. Suspect bursitis. Initial radiographs normal or inconclusive. 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 O 0 mSv O 0 mSv [ped] 9 9 1 0 0 0 0 0 1 2 12
US shoulder Usually appropriate O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 1 0 3 3 9
CT arthrography shoulder Usually not appropriate ☢☢☢☢ 10-30 mSv 1 1 14 0 2 0 0 0 0 0 0
CT shoulder with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 1 14 1 0 0 1 0 0 0 0
CT shoulder without IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 1 14 0 1 0 1 0 0 0 0
CT shoulder without and with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 1 15 1 0 0 0 0 0 0 0
X-ray arthrography shoulder Usually not appropriate ☢ <0.1 mSv 1 1 15 1 0 0 0 0 0 0 0
MR arthrography shoulder Usually not appropriate O 0 mSv O 0 mSv [ped] 1 1 13 0 1 1 1 0 0 0 0
MRI shoulder without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 1 15 0 0 1 0 0 0 0 0
Variant 5: Atraumatic shoulder pain. Suspect adhesive capsulitis. Initial radiographs normal or inconclusive. 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 O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 1 1 4 10
US shoulder May be appropriate (Disagreement) O 0 mSv O 0 mSv [ped] 5 5 2 0 1 5 4 3 1 0 0
X-ray arthrography shoulder May be appropriate ☢ <0.1 mSv 4 4 7 0 1 4 2 1 1 0 0
MR arthrography shoulder Usually not appropriate O 0 mSv O 0 mSv [ped] 2 2 7 2 3 1 3 0 0 0 0
CT arthrography shoulder Usually not appropriate ☢☢☢☢ 10-30 mSv 1 1 12 0 1 2 0 0 1 0 0
CT shoulder with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 1 15 1 0 0 0 0 0 0 0
CT shoulder without IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 1 15 1 0 0 0 0 0 0 0
CT shoulder without and with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 1 15 1 0 0 0 0 0 0 0
MRI shoulder without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 1 13 1 1 0 1 0 0 0 0
Variant 6: Atraumatic shoulder pain. Suspect biceps tendinitis, bursitis, dislocation or tear. Initial radiographs normal or inconclusive. 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 O 0 mSv O 0 mSv [ped] 8 8 1 0 0 0 2 0 5 1 7
US shoulder Usually appropriate O 0 mSv O 0 mSv [ped] 8 8 0 1 0 0 0 0 5 3 7
MR arthrography shoulder May be appropriate (Disagreement) O 0 mSv O 0 mSv [ped] 5 7 1 0 1 0 3 3 4 3 1
CT arthrography shoulder Usually not appropriate ☢☢☢☢ 10-30 mSv 1 1 12 0 1 2 1 0 0 0 0
CT shoulder with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 1 15 1 0 0 0 0 0 0 0
CT shoulder without IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 1 12 0 2 1 0 0 1 0 0
CT shoulder without and with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 1 16 0 0 0 0 0 0 0 0
X-ray arthrography shoulder Usually not appropriate ☢ <0.1 mSv 1 1 13 2 1 0 0 0 0 0 0
MRI shoulder without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 1 13 1 2 0 0 0 0 0 0
Variant 7: Pain after rotator cuff repair. Initial radiographs normal or inconclusive. 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 O 0 mSv O 0 mSv [ped] 9 9 0 0 0 1 1 1 1 4 8
MRI shoulder without IV contrast Usually appropriate O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 0 1 2 6 7
US shoulder Usually appropriate O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 0 0 2 12 2
CT arthrography shoulder May be appropriate ☢☢☢☢ 10-30 mSv 6 6 0 0 0 0 8 7 1 0 0
CT shoulder with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 1 15 1 0 0 0 0 0 0 0
CT shoulder without IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 1 13 1 2 0 0 0 0 0 0
CT shoulder without and with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 1 15 1 0 0 0 0 0 0 0
X-ray arthrography shoulder Usually not appropriate ☢ <0.1 mSv 1 1 13 0 2 1 0 0 0 0 0
MRI shoulder without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 1 10 2 0 1 2 1 0 0 0
Variant 8: Atraumatic shoulder pain. Neurogenic pain (excluding plexopathy). Initial imaging.
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 O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 1 1 14
US shoulder May be appropriate O 0 mSv O 0 mSv [ped] 5 5 0 0 0 0 12 4 0 0 0
CT shoulder without IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 2 2 8 1 1 1 3 2 0 0 0
Radiography shoulder Usually not appropriate ☢ <0.1 mSv 2 2 8 0 2 1 3 1 1 0 0
CT arthrography shoulder Usually not appropriate ☢☢☢☢ 10-30 mSv 1 1 14 0 1 1 0 0 0 0 0
CT shoulder with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 1 15 0 0 1 0 0 0 0 0
CT shoulder without and with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 1 15 0 1 0 0 0 0 0 0
X-ray arthrography shoulder Usually not appropriate ☢ <0.1 mSv 1 1 15 1 0 0 0 0 0 0 0
MR arthrography shoulder Usually not appropriate O 0 mSv O 0 mSv [ped] 1 1 14 0 1 1 0 0 0 0 0
MRI shoulder without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 1 16 0 0 0 0 0 0 0 0
Please refer to the supporting documentation for a more complete discussion of the concepts and their definitions below.
Final Tabulations:
A histogram of the number of panel members who rated the recommendation as noted in the column heading (ie, 1, 2, 3, …etc.)
Disagree:
The variation of the individual ratings from the median rating indicates panel disagreement on the final recommendation.
References:
Lists the references associated with the recommendation
SQ:
Study Quality (1, 2, 3, 4, Good M or Inadequate M) of the references listed.
RRL:
Information on the Relative Radiation Level (RRL) designations can be found here.