American College of Radiology
ACR Appropriateness Criteria®

Shoulder Pain-Traumatic

Variant 1: Traumatic 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 ☢ <0.1 mSv 9 9 0 0 0 0 0 0 0 0 15
CT arthrography shoulder Usually not appropriate ☢☢☢☢ 10-30 mSv 1 1 15 0 0 0 0 0 0 0 0
CT shoulder without IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 1 9 0 3 1 2 0 0 0 0
MR arthrography shoulder Usually not appropriate O 0 mSv O 0 mSv [ped] 1 1 14 0 0 0 1 0 0 0 0
MRI shoulder without IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 1 11 0 2 0 1 1 0 0 0
US shoulder Usually not appropriate O 0 mSv O 0 mSv [ped] 1 1 12 1 1 1 0 0 0 0 0
CT shoulder without and with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 1 13 1 1 0 0 0 0 0 0
CT shoulder with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 1 13 1 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 14 0 0 0 1 0 0 0 0
Tc-99m bone scan shoulder Usually not appropriate ☢☢☢ 1-10 mSv 1 1 14 0 1 0 0 0 0 0 0
FDG-PET/CT skull base to mid-thigh Usually not appropriate ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 1 15 0 0 0 0 0 0 0 0
Variant 2: Traumatic shoulder pain. Nonlocalized shoulder pain. Negative radiographs. 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 2 3 9
CT arthrography shoulder May be appropriate ☢☢☢☢ 10-30 mSv 5 5 6 0 0 1 6 2 0 0 0
US shoulder May be appropriate (Disagreement) O 0 mSv O 0 mSv [ped] 5 3 3 1 5 1 4 0 2 0 0
MR arthrography shoulder May be appropriate O 0 mSv O 0 mSv [ped] 5 5 0 0 1 0 9 2 3 0 1
CT shoulder without IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 3 3 2 3 4 0 5 1 0 1 0
Tc-99m bone scan shoulder Usually not appropriate ☢☢☢ 1-10 mSv 1 1 12 1 1 0 0 0 0 1 0
MRI shoulder without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 1 11 0 2 0 1 0 1 0 0
CT shoulder without and with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 1 15 0 0 0 0 0 0 0 0
CT shoulder with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 1 13 1 1 0 0 0 0 0 0
FDG-PET/CT skull base to mid-thigh Usually not appropriate ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 1 15 0 0 0 0 0 0 0 0
Variant 3: Traumatic shoulder pain. Radiographs show humeral head or neck 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 ☢☢☢ 1-10 mSv 9 9 0 0 0 0 0 0 1 1 13
MRI shoulder without IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 3 3 6 1 2 0 7 0 0 0 0
CT arthrography shoulder Usually not appropriate ☢☢☢☢ 10-30 mSv 1 1 11 2 0 1 0 1 0 0 0
CT shoulder with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 1 13 1 0 1 0 0 0 0 0
CT shoulder without and with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 1 14 0 0 1 0 0 0 0 0
FDG-PET/CT skull base to mid-thigh Usually not appropriate ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 1 11 1 1 2 0 0 0 0 0
MR arthrography shoulder Usually not appropriate O 0 mSv O 0 mSv [ped] 1 1 13 0 0 0 1 1 0 0 0
MRI shoulder without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 1 12 1 1 0 1 0 0 0 0
Tc-99m bone scan shoulder Usually not appropriate ☢☢☢ 1-10 mSv 1 1 8 2 0 3 1 1 0 0 0
US shoulder Usually not appropriate O 0 mSv O 0 mSv [ped] 1 1 9 2 1 2 0 1 0 0 0
Variant 4: Traumatic shoulder pain. Radiographs show scapula 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 ☢☢☢ 1-10 mSv 9 9 0 0 0 0 0 0 0 1 14
MRI shoulder without IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 3 3 4 1 4 2 3 1 0 0 0
CT arthrography shoulder Usually not appropriate ☢☢☢☢ 10-30 mSv 1 1 14 0 1 0 0 0 0 0 0
CT shoulder without and with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 1 14 0 0 1 0 0 0 0 0
FDG-PET/CT skull base to mid-thigh Usually not appropriate ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 1 11 0 1 3 0 0 0 0 0
CT shoulder with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 1 13 1 0 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 13 1 0 1 0 0 0 0 0
Tc-99m bone scan shoulder Usually not appropriate ☢☢☢ 1-10 mSv 1 1 8 3 0 4 0 0 0 0 0
US shoulder Usually not appropriate O 0 mSv O 0 mSv [ped] 1 1 14 1 0 0 0 0 0 0 0
MR arthrography shoulder Usually not appropriate O 0 mSv O 0 mSv [ped] 1 1 15 0 0 0 0 0 0 0 0
Variant 5: Traumatic shoulder pain. Radiographs show Bankart or Hill-Sachs lesion. 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 1 0 0 0 1 0 0 1 12
MRI shoulder without IV contrast Usually appropriate O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 0 2 5 3 5
CT arthrography shoulder May be appropriate ☢☢☢☢ 10-30 mSv 6 6 0 1 0 0 5 4 3 2 0
CT shoulder without IV contrast May be appropriate ☢☢☢ 1-10 mSv 6 6 0 0 0 0 6 3 5 2 0
CT shoulder with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 1 15 0 0 0 0 0 0 0 0
CT shoulder without and with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 1 15 0 0 0 0 0 0 0 0
FDG-PET/CT skull base to mid-thigh Usually not appropriate ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 1 15 0 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 11 0 1 1 2 0 0 0 0
Tc-99m bone scan shoulder Usually not appropriate ☢☢☢ 1-10 mSv 1 1 14 0 0 0 0 0 1 0 0
US shoulder Usually not appropriate O 0 mSv O 0 mSv [ped] 1 1 13 0 1 0 0 1 0 0 0
Variant 6: Traumatic shoulder pain. Radiographs normal. Physical examination and history consistent with dislocation event or instability. 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 0 14
MRI shoulder without IV contrast Usually appropriate O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 2 3 3 5 2
CT arthrography shoulder May be appropriate ☢☢☢☢ 10-30 mSv 6 6 0 0 0 0 4 4 4 1 2
CT shoulder without IV contrast May be appropriate ☢☢☢ 1-10 mSv 4 4 5 0 2 1 6 0 1 0 0
CT shoulder with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 1 12 1 1 0 0 1 0 0 0
CT shoulder without and with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 1 15 0 0 0 0 0 0 0 0
FDG-PET/CT skull base to mid-thigh Usually not appropriate ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 1 15 0 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 12 0 0 2 0 1 0 0 0
Tc-99m bone scan shoulder Usually not appropriate ☢☢☢ 1-10 mSv 1 1 14 0 0 0 0 0 1 0 0
US shoulder Usually not appropriate O 0 mSv O 0 mSv [ped] 1 1 10 0 1 1 2 1 0 0 0
Variant 7: Traumatic shoulder pain. Radiographs normal. Physical examination findings consistent with labral tear. 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 0 1 14
CT arthrography shoulder Usually appropriate ☢☢☢☢ 10-30 mSv 7 7 0 0 0 0 3 3 6 3 0
MRI shoulder without IV contrast Usually appropriate O 0 mSv O 0 mSv [ped] 7 7 0 0 1 0 1 2 5 3 3
CT shoulder without IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 1 11 1 1 1 0 0 1 0 0
US shoulder Usually not appropriate O 0 mSv O 0 mSv [ped] 1 1 11 1 2 0 1 0 0 0 0
Tc-99m bone scan shoulder Usually not appropriate ☢☢☢ 1-10 mSv 1 1 14 0 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 12 1 0 0 1 1 0 0 0
CT shoulder without and with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 1 14 1 0 0 0 0 0 0 0
CT shoulder with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 1 14 0 1 0 0 0 0 0 0
FDG-PET/CT skull base to mid-thigh Usually not appropriate ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 1 15 0 0 0 0 0 0 0 0
Variant 8: Traumatic shoulder pain. Radiographs normal. Physical examination findings consistent with rotator cuff tear. 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 2 3 10
MR arthrography shoulder Usually appropriate O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 2 1 4 3 5
US shoulder Usually appropriate O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 1 0 4 5 5
CT arthrography shoulder May be appropriate ☢☢☢☢ 10-30 mSv 6 6 1 0 0 1 2 7 1 3 0
CT shoulder with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 1 13 1 1 0 0 0 0 0 0
CT shoulder without and with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 1 14 0 1 0 0 0 0 0 0
CT shoulder without IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 1 12 1 1 0 0 0 0 1 0
FDG-PET/CT skull base to mid-thigh Usually not appropriate ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 1 15 0 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 12 1 1 0 1 0 0 0 0
Tc-99m bone scan shoulder Usually not appropriate ☢☢☢ 1-10 mSv 1 1 14 1 0 0 0 0 0 0 0
Variant 9: Traumatic shoulder pain. Radiographs already performed. Physical examination consistent with vascular compromise. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
CTA shoulder with IV contrast Usually appropriate ☢☢☢ 1-10 mSv 9 9 1 0 0 0 0 0 0 1 13
Arteriography shoulder Usually appropriate ☢☢☢ 1-10 mSv 7 7 1 0 0 0 4 0 5 1 4
US duplex Doppler shoulder May be appropriate O 0 mSv O 0 mSv [ped] 4 4 5 1 0 3 6 1 0 0 0
CT shoulder without and with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 1 13 0 1 0 1 0 0 0 0
CT shoulder without IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 1 11 0 2 0 2 0 0 0 0
FDG-PET/CT skull base to mid-thigh Usually not appropriate ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 1 15 0 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 12 1 1 0 0 0 0 1 0
MRI shoulder without IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 1 13 0 1 1 0 0 0 0 0
Tc-99m 3-phase bone scan shoulder Usually not appropriate ☢☢☢ 1-10 mSv 1 1 12 1 1 0 0 1 0 0 0
CT shoulder with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 1 14 0 1 0 0 0 0 0 1
MRA shoulder with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 1 11 3 1 0 1 0 0 0 0
Variant 10: Traumatic shoulder pain. Radiographs already performed. Neuropathic syndrome (excluding plexopathy). 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 1 3 3 5
Tc-99m bone scan shoulder May be appropriate ☢☢☢ 1-10 mSv 4 4 4 1 1 6 2 2 0 0 0
CT shoulder without IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 3 3 5 0 4 3 2 0 1 0 0
CT arthrography shoulder Usually not appropriate ☢☢☢☢ 10-30 mSv 1 1 13 0 2 0 0 0 0 0 0
CT shoulder with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 1 9 0 4 0 1 0 0 1 0
CT shoulder without and with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 1 12 0 1 0 2 0 0 0 0
FDG-PET/CT skull base to mid-thigh Usually not appropriate ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 1 15 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 0 0 0 0 0
US shoulder Usually not appropriate O 0 mSv O 0 mSv [ped] 1 1 11 0 0 1 2 1 0 0 0
MRI shoulder without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 1 10 3 1 0 2 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.