Chronic shoulder pain — suspected rotator cuff tear or impingement

ACR AC Chronic Shoulder Pain (2022 rev)

Radiographs first, then ultrasound or MRI depending on the question. For the cuff itself the two are close to equivalent and ultrasound is dynamic and cheap; MRI wins when the labrum, the marrow or the deeper soft tissues are in question.

Shoulder pain over weeks to months with a painful arc, weakness or night pain, usually in an outpatient orthopaedic or physiotherapy pathway.

Referenced decision support — confirm against your local protocol.

Decision support, not a directive. Protocols and timings shown are typical published ones — your local protocol takes precedence, and the vetting radiologist decides.

The request in front of you

Everything is optional. Leave a field alone and the answer assumes nothing — the verdict updates as you go.

Study requested

What the referrer actually asked for. It is evidence of intent, not a constraint on the right answer.

Contrast as written

What the request form says, not what it should say.

Age

Pick a band, or type an exact age if it matters.

years

Pregnancy status

Red flags

These accumulate rather than exclude. Back pain with one of these is a different question from back pain.

Renal risk factors

The question a vetter can actually answer from the request. An explicit “none known” is a real answer, and it removes checks rather than deferring them.

Previous contrast reaction

The pathway — tap anything already done

Marking a study complete moves the answer on. A patient arrives partway through a pathway far more often than at the start of one.

Accept as requested

Limb radiograph — two orthogonal views

Limb radiograph

What we'd amend, and why

Radiographs are the initial study in chronic shoulder pain: they demonstrate glenohumeral and acromioclavicular arthritis, calcific tendinopathy, a high-riding humeral head indicating chronic massive cuff tear, and the occasional unsuspected lesion. Several of these change the management before any soft-tissue imaging is done, and calcific tendinopathy in particular has its own treatment pathway.

Nothing needs resolving before this goes ahead. Routine checks below are owned downstream.

How was this decided?

pathwayany — All patients
rulerule-paeds-dose — Child-sized technique and contrast dose; checked by Radiographer at the scanner

Decision support only. Local protocol takes precedence.

Handled at the scanner(1)nothing for you to do

Settled and owned downstream. Each returns to a radiologist only on the stated trigger.

Child-sized technique and contrast dose
Confirm that a size- or weight-based protocol is selected — child-sized kV and mAs against size-based diagnostic reference ranges — and that contrast volume is calculated by weight rather than taken from an adult default. Weight-based iodinated contrast volumes of roughly 1.5–2.0 mL/kg are widely used in paediatric CT.
Radiographer at the scannerAt the scanner
Flags back if: No paediatric or size-based protocol exists on the scanner for the requested examination, or the requested coverage or number of phases exceeds what the clinical question needs — for example a multiphase study where a single phase answers it, or whole-body coverage for a focal question.

Worth asking the referrer (1)

None of these hold the request up. They sharpen the protocol or the plan that follows.

Is surgery being considered, and has the patient had physiotherapy?
It determines whether imaging changes management now or simply documents degenerative change that is common at this age.

Pathways

Big forks are separate pathways; the first whose conditions match is the one used.

Red flag for tumour or infection rather than degenerative cuff disease

Role	Study & protocol	Why this answers the question
First line	Limb radiograph Limb radiograph — two orthogonal views usually appropriate	Radiographs still lead, and here they lead for a different reason. In the ordinary cuff question they are looking for arthritis, calcific tendinopathy and a high-riding humeral head; with a red flag on the request they are looking for the unsuspected lesion the card already names — a lytic or destructive area, periosteal reaction, an erosion. They are immediate and they occasionally answer the question outright. What they cannot do is exclude: normal radiographs in this arm move the patient on rather than closing the episode.
Second line	MRI Shoulder MRI Shoulder — routine	This is where the arm differs from the ordinary cuff pathway: the cross-sectional study is MRI, not ultrasound. The card states the reason twice over — MRI is the choice when marrow pathology or a suspected mass is in question, and the limitation of ultrasound is the deep structures it cannot see. A known malignancy, a suspected infection or unexplained weight loss on a shoulder request puts marrow and the deep soft tissues at the centre of the question, and those are precisely the tissues a cuff ultrasound leaves unexamined. Intravenous contrast is not part of the routine cuff protocol; where the radiographs or the unenhanced study raise a mass or an infective collection, the dedicated soft-tissue mass and osteomyelitis pathways carry that question further.
Problem solving	Ultrasound musculoskeletal / soft tissue Ultrasound musculoskeletal / soft tissue	Ultrasound has not become useless — it still answers the cuff question dynamically, still assesses the biceps and the bursa, and still allows a guided injection — but in this arm it is no longer the equivalent alternative it is in the ordinary pathway. It is the study to add once the red flag has been resolved and a cuff tear remains the live question, or where a superficial soft-tissue lump is what the referrer is actually describing. It is not the study that excludes the thing the red flag was raised about.

MR arthrography is deliberately absent from this arm. It is an invasive joint injection aimed at the labrum, and it is the wrong procedure to add to a shoulder in which infection or tumour is the open question.
This arm changes which cross-sectional study answers the question. It does not change the referral: a shoulder lesion suspicious for tumour belongs on the soft tissue mass pathway and in a sarcoma service discussion, not in a cuff clinic.

All patients

Matches your inputsDefault

Role	Study & protocol	Why this answers the question
First line	Limb radiograph Limb radiograph — two orthogonal views usually appropriate	Radiographs are the initial study in chronic shoulder pain: they demonstrate glenohumeral and acromioclavicular arthritis, calcific tendinopathy, a high-riding humeral head indicating chronic massive cuff tear, and the occasional unsuspected lesion. Several of these change the management before any soft-tissue imaging is done, and calcific tendinopathy in particular has its own treatment pathway.
Reasonable alternative	Ultrasound musculoskeletal / soft tissue Ultrasound musculoskeletal / soft tissue	Ultrasound answers the cuff question directly and dynamically — tear presence, size and retraction, subacromial impingement in real movement, the long head of biceps, and the bursa — and it allows a guided injection in the same visit. Its limitations are operator dependence and the deep structures it cannot see.
Second line	MRI Shoulder MRI Shoulder — routine	MRI is the choice when more than the cuff is in question: muscle atrophy and fatty infiltration that determine whether a repair is feasible, marrow pathology, a suspected mass, or a normal ultrasound with persistent unexplained symptoms. Intravenous contrast is not required for the routine cuff question.
Problem solving	MR Arthrogram (Direct) MR Arthrogram — shoulder	MR arthrography is for the labrum and the capsular structures in a young patient with instability, or for a suspected partial articular-surface cuff tear, where distension separates structures that lie flat against each other on an unenhanced study. It is an invasive, joint-injection procedure and should not be requested for a straightforward cuff question.

Pitfalls

Requesting MRI before any radiograph, and then discovering advanced glenohumeral arthritis that made the cuff question irrelevant.
Reporting a degenerative cuff tear as the cause of symptoms without clinical correlation — asymptomatic tears become steadily more common with age.
Ordering an MR arthrogram for a suspected cuff tear, which adds an injection without adding to the answer.
Imaging a clinically obvious frozen shoulder; it is a clinical diagnosis, and imaging is mainly there to exclude something else.
Overlooking suprascapular or spinoglenoid notch pathology when the atrophy pattern does not match the cuff findings.

Priors — what to pull first

Previous shoulder surgery changes both the imaging appearances and the choice of study; anchors and suture material are a common source of misinterpretation.
A previous ultrasound documenting tear size makes today’s study a comparison rather than a fresh assessment.

What makes a good request

The useful question is what the result will change. If surgery is not being considered and the patient has not completed a course of physiotherapy, an early scan often does not alter management.
For a full-thickness cuff tear in experienced hands, ultrasound performs comparably to MRI and adds dynamic assessment of impingement and of the biceps tendon.
Suspected instability or a labral tear in a young patient is a different question and points towards MR arthrography.

How these studies are acquired

Contrast, phases and timing for every study on the pathways above.

Limb radiograph — two orthogonal views MRI Shoulder — routine Ultrasound musculoskeletal / soft tissue MR Arthrogram — shoulder

Confirm locally

Timings, contrast volumes and rates above are typical published values. Your department's protocol, scanner and patient population decide the actual numbers.
Safety thresholds and premedication policy follow local policy where it differs from the cited guidance.

References

Implemented from the cited published sources. Educational and workflow support only; confirm against current guidelines and local policy before clinical use.