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Variant 1: Chronic 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 Strong ☢ <0.1 mSv 9 9 0 0 0 0 0 0 0 0 17
References Study Quality
10 (18599231) 4
14 (31201467) 3
13 (29504320) 2
12 (30423642) 2
11 (32298371) 3
1 (28537759) 4
US shoulder May be appropriate Strong O 0 mSv O 0 mSv [ped] 5 5 2 1 0 2 9 1 0 0 0
References Study Quality
14 (31201467) 3
13 (29504320) 2
12 (30423642) 2
11 (32298371) 3
10 (18599231) 4
1 (28537759) 4
Image-guided anesthetic +/- corticosteroid injection shoulder or surrounding structures Usually not appropriate Expert Consensus Varies Varies 1 1 14 0 0 0 1 1 1 0 0
MR arthrography shoulder Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 14 0 0 2 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 14 1 0 1 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 2 0 2 1 0 0 0
Bone scan shoulder Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 15 1 1 0 0 0 0 0 0
CT shoulder with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 15 1 1 0 0 0 0 0 0
CT shoulder without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 15 1 1 0 0 0 0 0 0
CT shoulder without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 14 0 2 0 1 0 0 0 0
CT arthrography shoulder Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 14 1 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 15 1 0 1 0 0 0 0 0
Variant 2: Chronic shoulder pain. Suspect rotator cuff disorders or subacromial subdeltoid bursitis (no prior surgery). 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
US shoulder Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 0 0 4 5 8
References Study Quality
51 (8633460) 4
50 (29075914) 3
49 (27755645) 2
48 (32117542) 2
47 (32190853) Good
46 (32609088) 1
45 (19052931) 2
38 (15069134) 2
24 (19457838) M
MR arthrography shoulder Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 1 0 0 1 4 0 4 1 6
References Study Quality
33 (10227520) 3
32 (12147844) 3
31 (20563802) 3
30 (31773187) 3
29 (32195972) Good
28 (32241656) 4
27 (31831029) Good
26 (19098184) 3
25 (1489363) 3
24 (19457838) M
MRI shoulder without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 2 3 12
References Study Quality
42 (8865483) 4
41 (32077302) 3
40 (28273425) 3
39 (2740508) 3
38 (15069134) 2
37 (3496760) 3
29 (32195972) Good
28 (32241656) 4
27 (31831029) Good
Image-guided anesthetic +/- corticosteroid injection shoulder or surrounding structures May be appropriate Strong Varies Varies 5 5 0 0 1 2 8 2 2 0 0
References Study Quality
23 (31209618) 3
22 (27468666) 4
21 (31743987) 1
20 (32160504) 1
CT arthrography shoulder May be appropriate Strong ☢☢☢☢ 10-30 mSv 5 5 0 0 1 3 5 5 1 0 0
References Study Quality
18 (18400443) 4
17 (22919041) 2
16 (19556150) 2
15 (15911667) 3
Radiography shoulder additional views Usually not appropriate Limited ☢ <0.1 mSv 1 1 8 1 5 1 0 0 0 0 0
References Study Quality
44 (30367278) 3
43 (15671396) 3
42 (8865483) 4
MRI shoulder without and with IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 3 3 2 4 5 1 2 0 0 0 1
References Study Quality
36 (24938663) 2
35 (26260536) 2
34 (12942203) 4
Bone scan shoulder Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 15 1 0 0 1 0 0 0 0
CT shoulder with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 14 0 1 1 1 0 0 0 0
CT shoulder without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 14 0 2 1 0 0 0 0 0
CT shoulder without IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv 1 1 10 5 1 1 0 0 0 0 0
References Study Quality
19 (29573902) 3
FDG-PET/CT skull base to mid-thigh Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 15 1 1 0 0 0 0 0 0
Variant 3: Chronic shoulder pain. Radiographs demonstrate calcific tendinopathy or calcific bursitis. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Image-guided anesthetic +/- corticosteroid injection shoulder or surrounding structures Usually appropriate Strong Varies Varies 9 9 0 0 1 0 1 0 3 3 9
References Study Quality
67 (27909786) 2
66 (33040221) 4
65 (33719606) 2
64 (30975645) 1
63 (28613120) 1
62 (22143923) 1
61 (24813322) 4
60 (31124934) Good
59 (19959377) 2
58 (30204923) 2
57 (32114063) 1
56 (32451885) 2
55 (20414859) 2
54 (27554465) Good
US shoulder May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 0 0 0 1 4 10 0 0 0
References Study Quality
71 (33151457) 4
MR arthrography shoulder May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 0 0 1 11 2 0 1 0
References Study Quality
26 (19098184) 3
25 (1489363) 3
24 (19457838) M
68 (31816365) 4
69 (35297578) 2
MRI shoulder without IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 1 0 0 0 5 7 2 0 0
References Study Quality
52 (31650966) 4
68 (31816365) 4
70 (14500211) 4
Radiography shoulder additional views Usually not appropriate Expert Consensus ☢ <0.1 mSv 1 1 12 0 4 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 12 1 1 1 1 1 0 0 0
Bone scan shoulder Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 15 1 0 1 0 0 0 0 0
CT shoulder with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 14 2 0 0 1 0 0 0 0
CT shoulder without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 14 2 0 0 1 0 0 0 0
CT shoulder without IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv 1 1 8 2 4 0 1 0 0 0 0
References Study Quality
52 (31650966) 4
53 (8724130) 4
CT arthrography shoulder Usually not appropriate Limited ☢☢☢☢ 10-30 mSv 1 1 12 1 3 0 1 0 0 0 0
References Study Quality
18 (18400443) 4
FDG-PET/CT skull base to mid-thigh Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 15 1 1 0 0 0 0 0 0
Variant 4: Chronic shoulder pain. Suspect labral pathology or shoulder 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 Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 0 2 15
References Study Quality
94 (29754193) 3
93 (30476457) 3
92 (8058959) 4
91 (9275908) 2
90 (29582141) Good
89 (28604236) Good
88 (27826700) Good
73 (29549380) 3
31 (20563802) 3
30 (31773187) 3
MRI shoulder without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 0 0 1 2 0 5 6 3
References Study Quality
100 (28558115) 3
99 (27923707) 3
98 (32502712) 2
97 (29117482) 2
96 (29396694) 2
95 (21512082) 2
90 (29582141) Good
CT shoulder without IV contrast May be appropriate Strong ☢☢☢ 1-10 mSv 6 6 0 0 0 1 4 7 1 1 1
References Study Quality
87 (28756510) 1
86 (30898131) 4
85 (28593363) 4
84 (33270465) 3
83 (29198939) 3
82 (32712787) 2
81 (12728039) 4
80 (15827355) 4
79 (10462730) 4
78 (31056471) 4
77 (30470257) 3
CT arthrography shoulder May be appropriate Strong ☢☢☢☢ 10-30 mSv 6 6 0 0 0 1 1 7 4 2 2
References Study Quality
18 (18400443) 4
76 (24155283) 4
75 (31541346) 2
74 (30174813) 2
73 (29549380) 3
72 (22358006) 2
US shoulder Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 8 2 3 0 3 1 0 0 0
References Study Quality
101 (31912757) 3
Radiography shoulder additional views Usually not appropriate Limited ☢ <0.1 mSv 1 1 9 3 3 0 0 0 0 0 0
References Study Quality
1 (28537759) 4
Image-guided anesthetic +/- corticosteroid injection shoulder or surrounding structures Usually not appropriate Limited Varies Varies 1 1 13 0 3 0 0 0 1 0 0
References Study Quality
23 (31209618) 3
MRI shoulder without and with IV contrast Usually not appropriate Moderate O 0 mSv O 0 mSv [ped] 3 3 4 2 4 4 1 0 0 0 0
References Study Quality
34 (12942203) 4
89 (28604236) Good
Bone scan shoulder Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 16 1 0 0 0 0 0 0 0
CT shoulder with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 15 0 1 1 0 0 0 0 0
CT shoulder without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 15 0 1 1 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 16 0 1 0 0 0 0 0 0
Variant 5: Chronic 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
Image-guided anesthetic +/- corticosteroid injection shoulder or surrounding structures Usually appropriate Strong Varies Varies 8 8 0 0 1 0 2 0 3 4 7
References Study Quality
23 (31209618) 3
108 (28687319) 3
107 (27566475) 1
106 (33517741) 1
105 (28619380) 2
MRI shoulder without IV contrast Usually appropriate Moderate O 0 mSv O 0 mSv [ped] 8 8 1 0 0 0 2 2 1 5 6
References Study Quality
113 (23082152) 4
114 (28410478) 2
US shoulder May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 1 2 1 3 4 1 1 0 2
References Study Quality
108 (28687319) 3
117 (31782541) 3
116 (29770850) 3
115 (28900523) 1
MR arthrography shoulder May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 1 0 0 3 7 2 2 0 0
References Study Quality
109 (15358849) 3
Radiography shoulder additional views Usually not appropriate Expert Consensus ☢ <0.1 mSv 1 1 15 0 1 0 1 0 0 0 0
MRI shoulder without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 4 5 5 0 1 0 0 0 0
References Study Quality
112 (26611904) 3
111 (32591886) 2
110 (28729060) 4
Bone scan shoulder Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 16 0 1 0 0 0 0 0 0
CT shoulder with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 15 1 1 0 0 0 0 0 0
CT shoulder without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 15 1 1 0 0 0 0 0 0
CT shoulder without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 15 1 1 0 0 0 0 0 0
CT arthrography shoulder Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 14 0 2 0 1 0 0 0 0
FDG-PET/CT skull base to mid-thigh Usually not appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 13 0 3 0 0 0 1 0 0
References Study Quality
104 (28168397) 3
103 (28161721) 2
102 (32170356) 2
Variant 6: Chronic shoulder pain. Suspect biceps tendon abnormality. 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
US shoulder Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 0 1 4 3 1 3 5
References Study Quality
138 (31054148) 4
139 (31545834) 3
Image-guided anesthetic +/- corticosteroid injection shoulder or surrounding structures Usually appropriate Strong Varies Varies 8 8 0 0 1 0 2 2 3 2 7
References Study Quality
22 (27468666) 4
124 (31187487) 3
123 (31712838) 1
122 (31351537) 4
121 (27582534) 2
MR arthrography shoulder Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 1 2 4 6 4
References Study Quality
125 (9609174) 2
128 (28528385) 2
127 (28983764) 2
126 (31346668) 2
MRI shoulder without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 0 2 4 6 5
References Study Quality
130 (24891814) 3
129 (12591665) 3
131 (15111894) 2
137 (30937471) 2
136 (30271779) 2
135 (27885850) 2
134 (29573932) 2
133 (30639523) 2
132 (31153372) 2
CT arthrography shoulder May be appropriate Limited ☢☢☢☢ 10-30 mSv 4 4 3 1 2 4 5 1 1 0 0
References Study Quality
118 (30853414) 2
119 (28842745) 3
Radiography shoulder additional views Usually not appropriate Expert Consensus ☢ <0.1 mSv 1 1 15 0 2 0 0 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 12 1 1 0 1 2 0 0 0
Bone scan shoulder Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 16 1 0 0 0 0 0 0 0
CT shoulder with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 15 1 1 0 0 0 0 0 0
CT shoulder without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 15 1 1 0 0 0 0 0 0
CT shoulder without IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv 1 1 13 2 1 1 0 0 0 0 0
References Study Quality
120 (21367551) 2
FDG-PET/CT skull base to mid-thigh Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 16 0 1 0 0 0 0 0 0
Variant 7: Chronic shoulder pain. Initial radiographs demonstrate osteoarthritis. 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] 7 7 0 0 0 0 3 5 3 4 2
References Study Quality
144 (27765501) 3
143 (31864608) 3
142 (32241666) 4
Image-guided anesthetic +/- corticosteroid injection shoulder or surrounding structures May be appropriate Limited Varies Varies 6 6 0 0 1 0 5 4 5 0 0
References Study Quality
23 (31209618) 3
122 (31351537) 4
MR arthrography shoulder May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 5 5 0 0 0 3 9 1 2 0 0
CT shoulder without IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv 5 5 0 0 0 1 9 4 1 0 0
References Study Quality
19 (29573902) 3
141 (31955231) 3
140 (28872528) 4
CT arthrography shoulder May be appropriate Strong ☢☢☢☢ 10-30 mSv 5 5 1 0 1 0 8 2 2 0 3
References Study Quality
16 (19556150) 2
17 (22919041) 2
US shoulder Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 10 1 3 0 1 0 0 0 0
References Study Quality
142 (32241666) 4
Radiography shoulder additional views Usually not appropriate Strong ☢ <0.1 mSv 1 1 13 0 1 0 1 0 0 0 0
References Study Quality
148 (28735840) 3
147 (30528438) 2
146 (28943071) 4
145 (28395944) 2
MRI shoulder without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 14 0 0 1 1 1 0 0 0
Bone scan shoulder Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 16 0 0 0 1 0 0 0 0
CT shoulder with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 13 0 0 1 2 1 0 0 0
CT shoulder without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 14 0 2 0 0 1 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 15 0 2 0 0 0 0 0 0
Variant 8: Chronic shoulder pain. History of prior rotator cuff repair. Suspect rotator cuff disorders or subacromial subdeltoid 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
US shoulder Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 2 1 6 3 5
References Study Quality
158 (29398398) 3
157 (21719319) 2
MR arthrography shoulder Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 1 0 0 0 1 1 2 2 10
References Study Quality
152 (31078406) 4
151 (14730038) 4
150 (32241657) 4
MRI shoulder without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 5 2 10
References Study Quality
156 (27914845) 4
155 (28214172) 2
154 (31563430) 2
153 (22469406) 4
CT arthrography shoulder Usually appropriate Limited ☢☢☢☢ 10-30 mSv 7 7 1 0 0 0 2 5 3 5 1
References Study Quality
73 (29549380) 3
Image-guided anesthetic +/- corticosteroid injection shoulder or surrounding structures May be appropriate Limited Varies Varies 5 5 0 0 2 2 10 1 0 0 0
References Study Quality
149 (31084488) 1
Radiography shoulder additional views Usually not appropriate Expert Consensus ☢ <0.1 mSv 1 1 15 1 0 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 13 1 1 0 0 0 0 0 0
Bone scan shoulder Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 16 1 0 0 0 0 0 0 0
CT shoulder with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 15 0 1 1 0 0 0 0 0
CT shoulder without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 15 1 0 1 0 0 0 0 0
CT shoulder without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 14 1 2 0 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 15 2 0 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.