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Appropriateness Criteria

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