Population Covered By The Guidance
This pathway provides guidance on the imaging of adult patients following an acute shoulder injury.
Lead Researcher: Dr Sian Chin
Experts & Contributors: Dr Ravinder Dhillon, Dr Eamon Koh, Dr Michael Mason
Date reviewed: November 2018
Date Published: March 2019
Anterior Shoulder Dislocation
Supraspinatus Tendon Tear
Glenoid Labral Tear
- When imaging is required, shoulder radiography is the initial investigation of choice in acute traumatic shoulder pain and can identify or rule out several causes of pain including occult fracture, dislocation, malignancy, calcific tendonitis and avascular necrosis of the femoral head
- Rotator cuff injuries may be diagnosed clinically and managed conservatively. Imaging can be undertaken if pain is persistent. The role of imaging is to identify a full thickness rotator cuff tear that may be amenable to surgical treatment
- After fracture has been excluded, MRI is the preferred imaging modality to assess extra-articular soft-tissue traumatic pathology such as capsular and ligament tears
- If rotator cuff disease is suspected, ultrasound may be the first investigation after normal plain radiographs
- CT of the shoulder may be useful in complex fracture-dislocation injuries of the shoulder, as a pre-surgical tool
Date of literature search: April-August 2018
The search methodology is available on request. Email
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- American College of Radiology. ACR Appropriateness criteria. Shoulder pain - Atraumatic. 2018. (Guidelines). View the reference
- American College of Radiology. ACR Appropriateness criteria. Shoulder pain - traumatic. 2017. (Guidelines). View the reference
- Bahrs C, Rolauffs B, Südkamp NP, Schmal H, Eingartner C, Dietz K, et al. Indications for computed tomography (CT-) diagnostics in proximal humeral fractures: a comparative study of plain radiography and computed tomography. BMC Musculoskeletal Disorders. 2009;10(1):33. (Level II-III evidence). View the reference
- Jurik AG, Albrechtsen J. The use of computed tomography with two- and three-dimensional reconstructions in the diagnosis of three- and four-part fractures of the proximal humerus. Clin Radiol. 1994;49(11):800-4. (Level IV evidence). View the reference
- Dinnes J, Loveman E, McIntyre L, Waugh N. The effectiveness of diagnostic tests for the assessment of shoulder pain due to soft tissue disorders: a systematic review. Health Technol Assess. 2003;7(29):iii, 1-166. (Level II evidence). View the reference
- de Jesus JO, Parker L, Frangos AJ, Nazarian LN. Accuracy of MRI, MR arthrography, and ultrasound in the diagnosis of rotator cuff tears: a meta-analysis. AJR Am J Roentgenol. 2009;192(6):1701-7. (Level I evidence). View the reference
- Lenza M, Buchbinder R, Takwoingi Y, Johnston RV, Hanchard NC, Faloppa F. Magnetic resonance imaging, magnetic resonance arthrography and ultrasonography for assessing rotator cuff tears in people with shoulder pain for whom surgery is being considered. Cochrane Database Syst Rev. 2013(9):Cd009020. (Level I evidence). View the reference
- Chun KA, Kim MS, Kim YJ. Comparisons of the various partial-thickness rotator cuff tears on MR arthrography and arthroscopic correlation. Korean J Radiol. 2010;11(5):528-35. (Level II evidence). View the reference
- Smith TO, Drew BT, Toms AP. A meta-analysis of the diagnostic test accuracy of MRA and MRI for the detection of glenoid labral injury. Arch Orthop Trauma Surg. 2012;132(7):905-19. (Level I evidence). View the reference
- Jana M, Srivastava DN, Sharma R, Gamanagatti S, Nag HL, Mittal R, et al. Magnetic resonance arthrography for assessing severity of glenohumeral labroligamentous lesions. Journal of orthopaedic surgery (Hong Kong). 2012;20(2):230-5. (Level II-III evidence). View the reference
- van der Veen HC, Collins JP, Rijk PC. Value of magnetic resonance arthrography in post-traumatic anterior shoulder instability prior to arthroscopy: a prospective evaluation of MRA versus arthroscopy. Arch Orthop Trauma Surg. 2012;132(3):371-5. (Level II-III evidence). View the reference
- Jonas SC, Walton MJ, Sarangi PP. Is MRA an unnecessary expense in the management of a clinically unstable shoulder? A comparison of MRA and arthroscopic findings in 90 patients. Acta Orthop. 2012;83(3):267-70. (Level III evidence). View the reference
- Singh A, Thukral CL, Gupta K, Singh MI, Lata S, Arora RK. Role and correlation of high resolution ultrasound and magnetic resonance imaging in evaluation of patients with shoulder pain. Polish Journal of Radiology. 2017;82:410-7. (Level III evidence). View the reference
- Tuite MJ, Small KM. Imaging evaluation of nonacute shoulder pain. AJR Am J Roentgenol. 2017;209(3):525-33. (Review article). View the reference
- Friedman MV, Hillen TJ, Holland DV, Essenberg JM, Demertzis JL. Impact of shoulder sonography on clinical decision making. J Ultrasound Med. 2017;36(7):1365-71. (Level II evidence). View the reference
- Pavic R, Margetic P, Bensic M, Brnadic RL. Diagnostic value of US, MR and MR arthrography in shoulder instability. Injury. 2013;44 Suppl 3:S26-32. (Level II evidence). View the reference
Pathway User Guide
Yellow Boxes Denotes extra information. Some contain single or multiple white sub-boxes, click a white box to reveal detailed information in a pop-up.
White Boxes: Denotes standard pathway steps. (If inside a yellow box, they open a specific pop-up).
Zoom & Pan Controls: Use + / − or the slider to zoom. Reset returns to default. Tick Panning to drag the diagram when zoomed.
Blue “View Full Screen” Button: Opens the whole diagram in a large, full-screen pop-up window. Use Close to exit.
The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.
| SYMBOL | RRL | EFFECTIVE DOSE RANGE |
|---|---|---|
 |
None | 0 |
 |
Minimal | < 1 millisieverts |
 |
Low | 1-5 mSv |
 |
Medium | 5-10 mSv |
 |
High | >10 mSv |
Disclaimer
Status Of Recommendations Each pathway is designed to assist clinicians in situations when faced with a large array of possible diagnostic tests and examinations. However, it is recognised that diagnostic practice may differ from a particular pathway depending on local availability of equipment and expertise, as well as the experience of individual clinicians. Therefore each pathway is neither a rigid set of rules, nor a substitute for clinical assessment, and individual patient circumstances should always be considered.
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Plain Radiography
Plain Radiography
Initial investigation of choice for acute traumatic shoulder pain
- Initial investigation of choice for traumatic shoulder pain
- Can detect or rule out several causes of shoulder pain including fractures and dislocations, as well as identify other pathologies including calcific tendonitis, avascular necrosis, osteoarthritis, inflammatory arthropathies and bone tumours
- Different situations require different types of plain films (AP/lateral/axillary views). Shoulder trauma protocols should have ≥3 views, 2 of which are orthogonal
- Axillary, scapular Y-view and AP view are commonly used in trauma
Computed Tomography
Computed Tomography
Superior to plain radiographs in evaluation of complex fractures and fracture-dislocations involving the head of the humerus. CT can provide useful information about fracture complexity, displacement and angulation
- Superior to plain radiographs in evaluation of complex fractures and fracture-dislocations involving the head of the humerus
- Allows planning of treatment of complex proximal humeral fractures
Magnetic Resonance Imaging
Magnetic Resonance Imaging
Highly accurate in the evaluation of rotator cuff pathology and other soft tissue injuries as well as occult fracture and avascular necrosis
- After fracture has been excluded, MRI is the preferred imaging modality to assess extra-articular soft-tissue traumatic pathology such as capsular and ligament tears
- Allows accurate assessment of soft tissue injuries and has significant clinical impact
- Highly accurate in the assessment of full thickness rotator cuff tears, with sensitivity of 89-94% and specificity of 93%
- Equally sensitive to MR arthrography and comparable in clinical impact for full thickness rotator cuff tears, but can be less accurate in the detection of partial-thickness tears
- Comparable accuracy to US in the assessment of both full and partial thickness rotator cuff tears
- Indicated in the investigation of rotator cuff disease when US expertise is unavailable or when further investigation of rotator cuff pathology is needed
- Advantages:
- No ionising radiation
- Non-invasive
- Demonstrates other lesions such as acromioclavicular joint osteoarthritis, occult fractures and avascular necrosis
- Comprehensive display of soft tissue anatomy
- Demonstration of the causes for impingement
- Useful in characterisation and staging of bone tumours
- Limitations:
- Less specific than MR arthrography for rotator cuff tears, and less sensitive for detection of partial tears
- Cost
- May not be tolerated in claustrophobia, contraindicated with ferromagnetic prostheses
MRI Arthrography
MR Arthrography
Most accurate imaging modality for defining
- Rotator cuff pathology
- Labral/capsule abnormalities in gleno-humeral instability
- Involves an MRI following the intra-articular injection of a dilute contrast agent (gadolinium)
- Superior to MRI without intracapsular contrast, but may be less preferred in the acute setting due to joint effusion produced by intra-articular pathology
- Most accurate imaging modality for defining:
- Rotator cuff pathology
- 94-95% sensitive and 93-99% specific for full thickness tears, and 62-86% sensitive and 47-96% specific for partial thickness tears
- Superior depiction of partial-thickness tears compared to conventional MRI
- MR arthrography is less sensitive for bursal-sided partial thickness tears than articular-sided partial thickness tears
- Labral/capsule abnormalities in gleno-humeral instability
- Rotator cuff pathology
- Disadvantages: invasive, limited availability and high expense. Some studies report limited clinical value in patients already destined for arthroscopy
Ultrasonography
Ultrasonography
High sensitivity and specificity in the detection and staging of rotator cuff tears. Less accurate for partial thickness tears
- Useful to evaluate rotator cuff injuries but may be less useful in nonspecific traumatic shoulder pain. Can be considered to screen older patients with non-specific pain after trauma as rotator cuff tears are more common in this population
- High accuracy in the detection and staging of full-thickness rotator cuff tears, but less sensitive in partial-thickness tears
- Meta-analyses report a sensitivity of 87-92% for full-thickness tears with specificity of 93-96%, which is comparable to MRI
- MR arthrography is more sensitive and specific than both MR and US for identifying partial tears
- US is comparable to MRI in the hands of an experienced user. US may be considered for the initial imaging investigation if rotator cuff pathology is suspected ,
- Useful in guiding aspiration of calcium deposits or bursal injections
- Useful in evaluating the long head of biceps tendon, though MR and US are both less accurate for biceps tendon pathology compared to rotator cuff injuries
- There is evidence that US is useful in guiding clinical decision making
- US is inferior to MRI in the assessment of labroligamentous and osseous pathology
- Advantages:
- No ionising radiation
- Non-invasive
- No contrast agent
- Relatively inexpensive
- Readily available
- Limitations:
- User-dependent
- Less sensitive in detecting partial thickness rotator cuff tears
- Cannot accurately evaluate the labral-ligamentous complex and other deep shoulder structures