• Steinbach LS, Daffner RH, Dalinka MK, DeSmet AA, El-Khoury GY, Kneeland JB, Manaster BJ, Morrison WB, Pavlov H, Rubin DA, Weissman BN, Haralson RH III, Expert Panel on Musculoskeletal Imaging. Shoulder trauma. [online publication]. Reston (VA): American College of Radiology (ACR); 2005. 6 p. [37 references]

This is the current release of the guideline.

This guideline updates a previous version: Newberg A, Dalinka MK, Alazraki N, Berquist TH, Daffner RH, DeSmet AA, el-Khoury GY, Goergen TG, Keats TE, Manaster BJ, Pavlov H, Haralson RH, McCabe JB, Sartoris D. Shoulder trauma. American College of Radiology. ACR Appropriateness Criteria. Radiology 2000 Jun;215(Suppl):299-302.

The appropriateness criteria are reviewed annually and updated by the panels as needed, depending on introduction of new and highly significant scientific evidence.

ACR Appropriateness Criteria®

Clinical Condition: Acute Shoulder Trauma (e.g., MVA, Sports)

Variant 1: Rule out fracture or dislocation.

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

Variant 2: Acute or recent trauma, normal recent radiographs, significant clinical symptoms.

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

Variant 3: Subacute shoulder pain - questionable bursitis or tendonitis, approximately 3 months duration. First study recommended.

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

Variant 4: Subacute shoulder pain, suspect rotator cuff tear/impingement; over age 35. Normal plain radiographs or radiographs that demonstrate coracoacromial arch osteophytes/syndesmophytes.

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

Variant 5: Subacute shoulder pain, under age 35.

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

Variant 6: Subacute shoulder pain, suspect instability/labral tear.

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

Summary

The shoulder is the joint that is the most unstable, has the most mobility, and is difficult to assess clinically.

All radiographic shoulder studies should include frontal examinations with both internal and external humeral rotation. The frontal views can be done straight AP. AP to the scapula by turning the patient into a 30 degree posterior oblique (Grashey) projection, or in both projections, but the committee recommends obtaining at least one of the frontal projections in the Grashey position to profile the glenohumeral joint. Some patients should have an axillary lateral view, a scapular Y view, or both; one or the other is advisable if there is a question of instability or dislocation. The transthoracic view has little to offer but still seems to turn up when outside films become available for review. There have been several reports assessing special views for the evaluation of shoulder impingement and the anterior acromion. An upright 30-degree caudad-angled radiograph or a suprascapular outlet view will suffice in most cases.

Arthrography was the mainstay of evaluation for rotator cuff tear until the advent of shoulder MRI. Arthrography is currently used only as a potential study in patients with suspected rotator cuff disease who have a contraindication to MRI, in regions where shoulder US expertise is not available. CT is useful for characterizing fractures if more information is needed pre-operatively. It can demonstrate fracture complexity, displacement and angulation, especially with the use of reformations. CT arthrography is a second-line procedure for shoulders with suspected instability or labral disorders, when magnetic resonance (MR) arthrography and MRI are unavailable or contraindicated. US can be used to evaluate the tendons of the rotator cuff and the biceps. It is operator-dependent and limited in evaluation of the other important deep shoulder structures and marrow. It can be used to determine if a partial-thickness or full-thickness rotator cuff tear is present. Shoulder MRI is currently the procedure of choice for evaluation of occult fractures and the shoulder soft tissues, including the tendons, ligaments, muscles, and labrocapsular structures.

MRI can aid in detecting osseous and soft tissue abnormalities that may predispose to or be the result of shoulder impingement. The soft tissue abnormalities in the supraspinatus tendon, subacromial bursa, and biceps tendon are well seen. The osseous lesions include morphologic abnormalities of the acromion, acromioclavicular joint, and coracoacromial ligament. When a tendon has a signal intensity abnormality without focal disruption or associated findings to suggest a partial-thickness tear, the terms "tendinosis" or "tendinopathy" have been used to signify an underlying tendon degeneration or inflammation. These terms suggest that there is a chronic, often pre-existing degenerative process. The presence of tendinous enlargement and a heterogeneous signal pattern that demonstrates diffuse increased signal intensity on T1- weighting often with a slight increase in signal intensity on T2-weighting, is seen in patients with tendinosis. Partial-thickness tears of the rotator cuff can be seen inferiorly at the articular surface, superiorly at the bursal surface, or within the tendon substance. Tears at the articular surface are the most common type of partial-thickness tears. These are the only types of partial-thickness tears demonstrated by conventional shoulder arthrography. Full-thickness tears of the rotator cuff tendons can be accurately identified using conventional non-arthrographic MRI with high sensitivity and specificity. Increased signal intensity extending from the inferior to the superior surface of the tendon on all imaging sequences is an accurate sign of a full-thickness rotator cuff tear. Ten percent of rotator cuff tears will only present with morphologic changes. Tendon retraction, muscle atrophy, and fatty infiltration are important prognosticators. This type of information can be useful for decisions regarding conservative versus operative repair, type of operative repair (open, mini open, or arthroscopic cuff repair; substitute or muscle transfer) and to provide a postoperative prognosis. If there is any question concerning the distinction between a full-thickness and partial-thickness tear, MR arthrography is recommended. It is particularly helpful if the abnormal signal intensity extends from the undersurface of the tendon.

The shoulder joint is the most unstable joint in the body. Instability can be difficult to diagnose, and the pain produced by the unstable shoulder could be mistaken for that of shoulder impingement, cervical disc disease, acromioclavicular joint disease, and other processes. During the last decade, MRI has allowed for direct visualization of many of the lesions related to instability, aiding in diagnosis as well as therapeutic planning and follow-up. Although high resolution non-enhanced MRI has been shown to have high accuracy rates for demonstrating labral tears, direct MR arthrography with intra-articular injection of a dilute gadolinium solution has gained popularity during the last decade because of its ability to distend the joint and outline labral and capsular structures as well as the undersurface of the rotator cuff.

Abbreviations

• AP, anteroposterior
• CT, computed tomography
• MRI, magnetic resonance imaging
• MVA, motor vehicle accident
• NUC, nuclear medicine
• US, ultrasound

Algorithms were not developed from criteria guidelines.

The recommendations are based on analysis of the current literature and expert panel consensus.

• Steinbach LS, Daffner RH, Dalinka MK, DeSmet AA, El-Khoury GY, Kneeland JB, Manaster BJ, Morrison WB, Pavlov H, Rubin DA, Weissman BN, Haralson RH III, Expert Panel on Musculoskeletal Imaging. Shoulder trauma. [online publication]. Reston (VA): American College of Radiology (ACR); 2005. 6 p. [37 references]

Not applicable: The guideline was not adapted from another source.

1995 (revised 2005)

American College of Radiology - Medical Specialty Society

American College of Radiology (ACR) provided the funding and the resources for these ACR Appropriateness Criteria®.

Committee on Appropriateness Criteria, Expert Panel on Musculoskeletal Imaging

Panel Members: Lynne S. Steinbach, MD; Murray K. Dalinka, MD; Richard H. Daffner, MD; Arthur A. DeSmet, MD; George Y. El-Khoury, MD; John B. Kneeland, MD; B.J. Manaster, MD, PhD; William B. Morrison, MD; Helene Pavlov, MD; David A. Rubin, MD; Barbara N. Weissman, MD; Robert H. Haralson III, MD

Not stated

This is the current release of the guideline.

This guideline updates a previous version: Newberg A, Dalinka MK, Alazraki N, Berquist TH, Daffner RH, DeSmet AA, el-Khoury GY, Goergen TG, Keats TE, Manaster BJ, Pavlov H, Haralson RH, McCabe JB, Sartoris D. Shoulder trauma. American College of Radiology. ACR Appropriateness Criteria. Radiology 2000 Jun;215(Suppl):299-302.

The appropriateness criteria are reviewed annually and updated by the panels as needed, depending on introduction of new and highly significant scientific evidence.

None available

This summary was completed by ECRI on May 6, 2001. The information was verified by the guideline developer as of June 29, 2001. This NGC summary was updated by ECRI on January 31, 2006. This summary was updated by ECRI Institute on May 17, 2007 following the U.S. Food and Drug Administration (FDA) advisory on Gadolinium-based contrast agents. This summary was updated by ECRI Institute on June 20, 2007 following the U.S. Food and Drug Administration (FDA) advisory on gadolinium-based contrast agents.