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Variant 1: Any etiology; best initial study. X-ray shoulder 9 X CT shoulder without contrast 1 XXX CT arthrography shoulder 1 XX MRI shoulder without contrast 1 0 MR arthrography shoulder 1 0 US shoulder 1 0 X-ray arthrography shoulder 1 X

Variant 2: Radiographs noncontributory. Persistent significant pain. Next study. MRI shoulder without contrast 9 0 CT arthrography shoulder 5 If MRI contraindicated. XX US shoulder 5 If MRI contraindicated. 0 MR arthrography shoulder 1 0 CT shoulder without contrast 1 XXX X-ray arthrography shoulder 1 X X-ray arthrography shoulder with anesthetic and/or corticosteroid 1 X

Variant 3: Radiographs noncontributory. Age less than 35 years, suspect labral tear with or without instability on physical examination. MR arthrography shoulder 9 See footnote regarding anticipated exceptions.• 0 MRI shoulder without contrast 7 With optimized imaging equipment. 0 CT arthrography shoulder 5 If MRI contraindicated. XX CT shoulder without contrast 1 XXX US shoulder 1 0 X-ray arthrography shoulder 1 X

Variant 4: Radiographs noncontributory. Questionable bursitis or long head of biceps tenosynovitis based on clinical findings including physical examination. MRI shoulder without contrast 9 MRI and US are equivalent in this evaluation. 0 US shoulder 9 MRI and US are equivalent in this evaluation. If local expertise available. Study may include injection of anesthetic and/or corticosteroid if clinically warranted. 0 CT shoulder without contrast 1 XXX CT arthrography shoulder 1 XX MR arthrography shoulder 1 0 X-ray arthrography shoulder 1 X X-ray shoulder bursography/tenography with anesthetic and/or corticosteroid 1 X

Variant 5: Normal radiographs or radiographs that demonstrate coracoacromial arch osteophytes/syndesmophytes. Suspect rotator cuff tear/impingement, over age 35 years. MRI shoulder without contrast 9 0 US shoulder 8 0 MR arthrography shoulder 7 See footnote regarding anticipated exceptions.• 0 CT arthrography shoulder 5 If MR or US cannot be performed. XX X-ray arthrography shoulder 1 X CT shoulder without contrast 1 XXX

Variant 6: Radiographs noncontributory. Previous total shoulder arthroplasty. Suspect rotator cuff tear. US shoulder 9 0 X-ray arthrography shoulder 8 If US expertise not available. X CT arthrography shoulder 7 With optimized imaging equipment. XX MR arthrography shoulder 6 See footnote regarding anticipated exceptions.• 0 MRI shoulder without contrast 5 With dedicated metal suppression protocol. 0 CT shoulder without contrast 1 XXX

Variant 7: Radiographs noncontributory. Status post prior rotator cuff repair. Suspect re-tear. MRI shoulder without contrast 9 MRI, MR arthrography, and US are equivalent in this evaluation, depending on local expertise. 0 MR arthrography shoulder 9 MRI, MR arthrography, and US are equivalent in this evaluation, depending on local expertise. See footnote regarding anticipated exceptions.• 0 US shoulder 9 MRI, MR arthrography, and US are equivalent in this evaluation, depending on local expertise. 0 X-ray arthrography shoulder 5 If MRI or US cannot be performed. X CT arthrography shoulder 5 If MRI or US cannot be performed. XX CT shoulder without contrast 1 XXX

Variant 8: Radiographs noncontributory. Suspect septic arthritis. US arthrocentesis shoulder 9 US and x-ray guidance are equivalent. 0 X-ray arthrocentesis shoulder 9 US and x-ray guidance are equivalent. X MRI shoulder without and with contrast 7 Aspiration is the procedure of choice. May be appropriate if clinical concern warrants. See footnote regarding anticipated exceptions.• 0 MRI shoulder without contrast 6 Aspiration is the procedure of choice. May be appropriate if clinical concern warrants. 0 CT shoulder without and with contrast 5 Aspiration is the procedure of choice. May be appropriate if clinical concern warrants. XXX CT arthrography shoulder 1 XX MR arthrography shoulder 1 0 US shoulder 1 0 CT shoulder without contrast 1 XXX Relative radiation level designations Relative radiation level Adult effective dose estimate range Pediatric effective dose estimate range 0 0 mSv 0 mSv X <0.1 mSv <0.03 mSv XX 0.1-1 mSv 0.03-0.3 mSv XXX 1-10 mSv 0.3-3 mSv XXXX 10-30 mSv 3-10 mSv XXXXX 30-100 mSv 10-30 mSv RRL assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (eg, region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as NS (not specified).

10-30 mSv RRL assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (eg, region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as NS (not specified). Rating scale: 1, 2, 3: usually not appropriate; 4, 5, 6: may be appropriate; 7, 8, 9: usually appropriate. * RRL: relative radiation level. See "Relative radiation level designations" table on right for corresponding adult and pediatric ranges. • Anticipated exceptions: Nephrogenic systemic fibrosis (NSF) is a disorder with a scleroderma-like presentation and a spectrum of manifestations that can range from limited clinical sequelae to fatality. It appears to be related to both underlying severe renal dysfunction and the administration of gadolinium-based contrast agents. It has occurred primarily in patients on dialysis, rarely in patients with very limited glomerular filtration rate (GFR) (ie, <30 mL/min/1.73m 2 ), and almost never in other patients. There is growing literature regarding NSF. Although some controversy and lack of clarity remain, there is a consensus that it is advisable to avoid all gadolinium-based contrast agents in dialysis-dependent patients unless the possible benefits clearly outweigh the risk, and to limit the type and amount in patients with estimated GFR rates <30 mL/min/1.73m 2 . Reproduced with permission from: Shoulder trauma. American College of Radiology. ACR Appropriateness Criteria. Copyright © 2010 American College of Radiology. The complete version of the ACR Appropriateness Criteria® Shoulder Trauma topic can be accessed on the ACR website at www.acr.org .