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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 Limited ☢ <0.1 mSv 9 9 0 0 0 0 0 0 0 0 16
References Study Quality
2 (18599231) 4
US shoulder Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 12 1 1 1 0 1 0 0 0
References Study Quality
7 (-3110180) 2
X-ray arthrography shoulder Usually not appropriate Expert Consensus ☢ <0.1 mSv 1 1 16 0 0 0 0 0 0 0 0
MR arthrography shoulder Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 14 0 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 14 0 1 1 0 0 0 0 0
MRI shoulder without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 0 0 1 1 2 0 0 0
CT shoulder with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 15 0 1 0 0 0 0 0 0
CT shoulder without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 16 0 0 0 0 0 0 0 0
CT shoulder without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 13 1 1 1 0 0 0 0 0
CT arthrography shoulder Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 15 0 1 0 0 0 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
US shoulder Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 1 0 0 0 2 0 3 4 6
References Study Quality
25 (15069134) 2
35 (20414859) 2
33 (23401583) 4
34 (19052931) 2
36 (19959377) 2
MRI shoulder without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 0 3 13
References Study Quality
27 (8249731) 3
29 (14500211) 4
13 (19931132) 4
28 (1489363) 3
25 (15069134) 2
24 (3496760) 3
23 (2740508) 3
26 (-3101660) 4
5 (1985990) 3
MR arthrography shoulder May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 6 6 0 0 2 0 6 5 2 0 1
CT arthrography shoulder May be appropriate Strong ☢☢☢☢ 10-30 mSv 5 5 0 0 0 2 12 2 0 0 0
References Study Quality
18 (15911667) 3
21 (18400443) 4
20 (22919041) 2
22 (16969638) 3
19 (19556150) 2
Radiography shoulder additional views Usually not appropriate Strong ☢ <0.1 mSv 2 2 7 5 0 0 3 0 0 0 1
References Study Quality
2 (18599231) 4
8 (6766616) 3
9 (6766615) 3
10 (2773735) 4
13 (19931132) 4
15 (-3101631) 4
11 (15671396) 3
12 (13721957) 2
14 (18562731) 2
X-ray arthrography shoulder Usually not appropriate Expert Consensus ☢ <0.1 mSv 1 1 9 1 0 4 1 0 1 0 0
MRI shoulder without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 14 0 1 0 1 0 0 0 0
CT shoulder with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 15 1 0 0 0 0 0 0 0
CT shoulder without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv 1 1 16 0 0 0 0 0 0 0 0
References Study Quality
13 (19931132) 4
16 (15100546) 4
17 (8724130) 4
CT shoulder without IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv 1 1 10 1 1 0 2 1 1 0 0
References Study Quality
13 (19931132) 4
16 (15100546) 4
17 (8724130) 4
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 Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 1 3 12
References Study Quality
27 (8249731) 3
53 (9275908) 2
52 (26295662) 4
54 (8058959) 4
55 (24623367) 3
49 (8115604) 2
50 (7480762) 2
51 (16244267) 3
MRI shoulder without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 8 8 1 0 0 0 2 1 4 4 4
References Study Quality
48 (21512082) 2
46 (15385288) 4
47 (7726053) 3
40 (22469405) 4
CT arthrography shoulder May be appropriate Limited ☢☢☢☢ 10-30 mSv 6 6 0 0 0 0 7 8 1 0 0
References Study Quality
37 (24155283) 4
21 (18400443) 4
45 (22358006) 2
US shoulder Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 10 1 1 2 2 0 0 0 0
References Study Quality
52 (26295662) 4
Radiography shoulder additional views Usually not appropriate Limited ☢ <0.1 mSv 1 1 9 4 0 1 0 1 1 0 0
References Study Quality
2 (18599231) 4
37 (24155283) 4
X-ray arthrography shoulder Usually not appropriate Expert Consensus ☢ <0.1 mSv 1 1 14 1 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 14 0 2 0 0 0 0 0 0
CT shoulder with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 15 1 0 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 0 0 0 0 0 0 0
CT shoulder without IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv 1 1 14 0 1 0 0 0 1 0 0
References Study Quality
37 (24155283) 4
38 (19887292) 4
42 (21808996) 4
39 (21603873) 3
41 (10462730) 4
40 (22469405) 4
44 (12728039) 4
43 (15827355) 4
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
US shoulder Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 1 0 3 3 9
References Study Quality
59 (8633460) 4
60 (11149524) 4
MRI shoulder without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 1 0 0 0 0 0 1 2 12
References Study Quality
56 (8865483) 4
X-ray arthrography shoulder Usually not appropriate Expert Consensus ☢ <0.1 mSv 1 1 15 1 0 0 0 0 0 0 0
MR arthrography shoulder Usually not appropriate Expert Consensus 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 Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 15 0 0 1 0 0 0 0 0
CT shoulder with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 14 1 0 0 1 0 0 0 0
CT shoulder without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 15 1 0 0 0 0 0 0 0
CT shoulder without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 14 0 1 0 1 0 0 0 0
CT arthrography shoulder Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 14 0 2 0 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 Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 1 1 4 10
References Study Quality
65 (7754892) 3
64 (23082152) 4
US shoulder May be appropriate (Disagreement) Expert Opinion 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 Limited ☢ <0.1 mSv 4 4 7 0 1 4 2 1 1 0 0
References Study Quality
62 (1516300) 3
63 (7432760) 4
MR arthrography shoulder Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 7 2 3 1 3 0 0 0 0
References Study Quality
68 (15358849) 3
67 (11465773) 4
MRI shoulder without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 13 1 1 0 1 0 0 0 0
References Study Quality
66 (9437603) 4
CT shoulder with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 15 1 0 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 0 0 0 0 0 0 0
CT shoulder without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 15 1 0 0 0 0 0 0 0
CT arthrography shoulder Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 12 0 1 2 0 0 1 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
US shoulder Usually appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 8 8 0 1 0 0 0 0 5 3 7
MRI shoulder without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 8 8 1 0 0 0 2 0 5 1 7
References Study Quality
73 (24891814) 3
72 (12591665) 3
74 (15111894) 2
MR arthrography shoulder May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 1 0 1 0 3 3 4 3 1
References Study Quality
75 (9609174) 2
X-ray arthrography shoulder Usually not appropriate Expert Consensus ☢ <0.1 mSv 1 1 13 2 1 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 13 1 2 0 0 0 0 0 0
CT shoulder with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 15 1 0 0 0 0 0 0 0
CT shoulder without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 16 0 0 0 0 0 0 0 0
CT shoulder without IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv 1 1 12 0 2 1 0 0 1 0 0
References Study Quality
70 (2027968) 4
69 (21367551) 2
71 (10543593) 4
CT arthrography shoulder Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 12 0 1 2 1 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
US shoulder Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 0 0 2 12 2
References Study Quality
82 (21719313) 2
83 (21719319) 2
MR arthrography shoulder Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 1 1 1 1 4 8
References Study Quality
77 (22469406) 4
81 (23351978) 1
80 (10580942) 4
79 (14730038) 4
78 (23345200) 4
MRI shoulder without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 0 1 2 6 7
References Study Quality
77 (22469406) 4
81 (23351978) 1
80 (10580942) 4
79 (14730038) 4
78 (23345200) 4
CT arthrography shoulder May be appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 6 6 0 0 0 0 8 7 1 0 0
X-ray arthrography shoulder Usually not appropriate Expert Consensus ☢ <0.1 mSv 1 1 13 0 2 1 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 10 2 0 1 2 1 0 0 0
CT shoulder with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 15 1 0 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 0 0 0 0 0 0 0
CT shoulder without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 13 1 2 0 0 0 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 Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 1 1 14
References Study Quality
90 (21536461) 4
85 (25714290) 4
89 (21415181) 4
88 (23125929) 4
87 (10550533) 4
91 (21862800) 4
US shoulder May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 0 0 0 12 4 0 0 0
References Study Quality
94 (12640155) 4
93 (7933041) 4
92 (10447077) 2
Radiography shoulder Usually not appropriate Limited ☢ <0.1 mSv 2 2 8 0 2 1 3 1 1 0 0
References Study Quality
86 (20926731) 4
X-ray arthrography shoulder Usually not appropriate Expert Consensus ☢ <0.1 mSv 1 1 15 1 0 0 0 0 0 0 0
MR arthrography shoulder Usually not appropriate Expert Consensus 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 Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 16 0 0 0 0 0 0 0 0
CT shoulder with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 15 0 0 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 0 0 0 0 0 0
CT shoulder without IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv 2 2 8 1 1 1 3 2 0 0 0
References Study Quality
86 (20926731) 4
CT arthrography shoulder Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 14 0 1 1 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.