Chronic Ankle Pain

Variant: 1 Adult. Chronic ankle pain. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
Radiography ankle	Usually Appropriate	☢
US ankle	Usually Not Appropriate	O
MRI ankle without and with IV contrast	Usually Not Appropriate	O
MRI ankle without IV contrast	Usually Not Appropriate	O
CT ankle with IV contrast	Usually Not Appropriate	☢
CT ankle without and with IV contrast	Usually Not Appropriate	☢
CT ankle without IV contrast	Usually Not Appropriate	☢
Bone scan ankle	Usually Not Appropriate	☢☢☢

Variant: 2 Adult. Chronic ankle pain. Suspected osteoarthritis or early impingement. Radiographs performed. Next imaging study.

Procedure	Appropriateness Category	Relative Radiation Level
MRI ankle without IV contrast	Usually Appropriate	O
CT ankle without IV contrast	Usually Appropriate	☢
US ankle	Usually Not Appropriate	O
MR arthrography ankle	Usually Not Appropriate	O
MRI ankle without and with IV contrast	Usually Not Appropriate	O
CT ankle with IV contrast	Usually Not Appropriate	☢
CT ankle without and with IV contrast	Usually Not Appropriate	☢
CT arthrography ankle	Usually Not Appropriate	☢
Bone scan ankle	Usually Not Appropriate	☢☢☢

Variant: 3 Adult. Chronic ankle pain. Suspected osteochondral lesion. Radiographs performed. Next imaging study.

Procedure	Appropriateness Category	Relative Radiation Level
MRI ankle without IV contrast	Usually Appropriate	O
CT ankle without IV contrast	Usually Appropriate	☢
CT arthrography ankle	May Be Appropriate	☢
US ankle	Usually Not Appropriate	O
MR arthrography ankle	Usually Not Appropriate	O
MRI ankle without and with IV contrast	Usually Not Appropriate	O
CT ankle with IV contrast	Usually Not Appropriate	☢
CT ankle without and with IV contrast	Usually Not Appropriate	☢
Bone scan ankle	Usually Not Appropriate	☢☢☢

Variant: 4 Adult. Chronic ankle pain. Suspected tarsal coalition. Radiographs performed. Next imaging study.

Procedure	Appropriateness Category	Relative Radiation Level
MRI ankle without IV contrast	Usually Appropriate	O
CT ankle without IV contrast	Usually Appropriate	☢
US ankle	Usually Not Appropriate	O
MR arthrography ankle	Usually Not Appropriate	O
MRI ankle without and with IV contrast	Usually Not Appropriate	O
CT ankle with IV contrast	Usually Not Appropriate	☢
CT ankle without and with IV contrast	Usually Not Appropriate	☢
CT arthrography ankle	Usually Not Appropriate	☢
Bone scan ankle	Usually Not Appropriate	☢☢☢

Variant: 5 Adult. Chronic ankle pain. Suspected instability or ligamentous injury. Radiographs performed. Next imaging study.

Procedure	Appropriateness Category	Relative Radiation Level
MRI ankle without IV contrast	Usually Appropriate	O
US ankle	May Be Appropriate	O
Radiography ankle stress views	May Be Appropriate	☢
MR arthrography ankle	Usually Not Appropriate	O
MRI ankle without and with IV contrast	Usually Not Appropriate	O
CT ankle with IV contrast	Usually Not Appropriate	☢
CT ankle without and with IV contrast	Usually Not Appropriate	☢
CT ankle without IV contrast	Usually Not Appropriate	☢
CT arthrography ankle	Usually Not Appropriate	☢
Bone scan ankle	Usually Not Appropriate	☢☢☢

Variant: 6 Adult. Chronic ankle pain. Suspected tendon pathology. Radiographs performed. Next imaging study.

Procedure	Appropriateness Category	Relative Radiation Level
US ankle	Usually Appropriate	O
MRI ankle without IV contrast	Usually Appropriate	O
MR arthrography ankle	Usually Not Appropriate	O
MRI ankle without and with IV contrast	Usually Not Appropriate	O
CT ankle with IV contrast	Usually Not Appropriate	☢
CT ankle without and with IV contrast	Usually Not Appropriate	☢
CT ankle without IV contrast	Usually Not Appropriate	☢
CT arthrography ankle	Usually Not Appropriate	☢
Bone scan ankle	Usually Not Appropriate	☢☢☢

Panel Members

Alison Schonberger, MD, MS^a, Roger J. Bartolotta, MD^b, Alice S. Ha, MD, MS^c, Thanda Aung, MD, MS^d, Cyrus P. Bateni, MD^e, Steve B. Behrens, MD^f, Christian S. Geannette, MD^g, Olga Laur, MD^h, Robert W. Morris, MDⁱ, Deepa Rajakrishnan, MD, MBA^j, Michael G. Fox, MD, MBA^k

Summary of Literature Review

Introduction/Background

Special Imaging Considerations

Initial Imaging Definition

Initial imaging is defined as imaging at the beginning of the care episode for the medical condition defined by the variant. More than one procedure can be considered usually appropriate in the initial imaging evaluation when:

There are procedures that are equivalent alternatives (ie, only one procedure will be ordered to provide the clinical information to effectively manage the patient’s care)

There are complementary procedures (ie, more than one procedure is ordered as a set or simultaneously wherein each procedure provides unique clinical information to effectively manage the patient’s care).

Discussion of Procedures by Variant

Variant 1:Adult. Chronic ankle pain. Initial imaging.

Variant 1:Adult. Chronic ankle pain. Initial imaging.
A. Bone scan ankle

Variant 1:Adult. Chronic ankle pain. Initial imaging.
B. CT ankle with IV contrast

Variant 1:Adult. Chronic ankle pain. Initial imaging.
C. CT ankle without and with IV contrast

Variant 1:Adult. Chronic ankle pain. Initial imaging.
D. CT ankle without IV contrast

Variant 1:Adult. Chronic ankle pain. Initial imaging.
E. MRI ankle without and with IV contrast

Variant 1:Adult. Chronic ankle pain. Initial imaging.
F. MRI ankle without IV contrast

Variant 1:Adult. Chronic ankle pain. Initial imaging.
G. Radiography ankle

Variant 1:Adult. Chronic ankle pain. Initial imaging.
H. US ankle

Variant 2:Adult. Chronic ankle pain. Suspected osteoarthritis or early impingement. Radiographs performed. Next imaging study.

Variant 2:Adult. Chronic ankle pain. Suspected osteoarthritis or early impingement. Radiographs performed. Next imaging study.
A. Bone scan ankle

Variant 2:Adult. Chronic ankle pain. Suspected osteoarthritis or early impingement. Radiographs performed. Next imaging study.
B. CT ankle with IV contrast

Variant 2:Adult. Chronic ankle pain. Suspected osteoarthritis or early impingement. Radiographs performed. Next imaging study.
C. CT ankle without and with IV contrast

Variant 2:Adult. Chronic ankle pain. Suspected osteoarthritis or early impingement. Radiographs performed. Next imaging study.
D. CT ankle without IV contrast

Variant 2:Adult. Chronic ankle pain. Suspected osteoarthritis or early impingement. Radiographs performed. Next imaging study.
E. CT arthrography ankle

Variant 2:Adult. Chronic ankle pain. Suspected osteoarthritis or early impingement. Radiographs performed. Next imaging study.
F. MR arthrography ankle

Variant 2:Adult. Chronic ankle pain. Suspected osteoarthritis or early impingement. Radiographs performed. Next imaging study.
G. MRI ankle without and with IV contrast

Variant 2:Adult. Chronic ankle pain. Suspected osteoarthritis or early impingement. Radiographs performed. Next imaging study.
H. MRI ankle without IV contrast

Variant 2:Adult. Chronic ankle pain. Suspected osteoarthritis or early impingement. Radiographs performed. Next imaging study.
I. US ankle

Variant 3:Adult. Chronic ankle pain. Suspected osteochondral lesion. Radiographs performed. Next imaging study.

Variant 3:Adult. Chronic ankle pain. Suspected osteochondral lesion. Radiographs performed. Next imaging study.
A. Bone scan ankle

Variant 3:Adult. Chronic ankle pain. Suspected osteochondral lesion. Radiographs performed. Next imaging study.
B. CT ankle with IV contrast

Variant 3:Adult. Chronic ankle pain. Suspected osteochondral lesion. Radiographs performed. Next imaging study.
C. CT ankle without and with IV contrast

Variant 3:Adult. Chronic ankle pain. Suspected osteochondral lesion. Radiographs performed. Next imaging study.
D. CT ankle without IV contrast

Variant 3:Adult. Chronic ankle pain. Suspected osteochondral lesion. Radiographs performed. Next imaging study.
E. CT arthrography ankle

Variant 3:Adult. Chronic ankle pain. Suspected osteochondral lesion. Radiographs performed. Next imaging study.
F. MR arthrography ankle

Variant 3:Adult. Chronic ankle pain. Suspected osteochondral lesion. Radiographs performed. Next imaging study.
G. MRI ankle without and with IV contrast

Variant 3:Adult. Chronic ankle pain. Suspected osteochondral lesion. Radiographs performed. Next imaging study.
H. MRI ankle without IV contrast

Variant 3:Adult. Chronic ankle pain. Suspected osteochondral lesion. Radiographs performed. Next imaging study.
I. US ankle

Variant 4:Adult. Chronic ankle pain. Suspected tarsal coalition. Radiographs performed. Next imaging study.

Variant 4:Adult. Chronic ankle pain. Suspected tarsal coalition. Radiographs performed. Next imaging study.
A. Bone scan ankle

Variant 4:Adult. Chronic ankle pain. Suspected tarsal coalition. Radiographs performed. Next imaging study.
B. CT ankle with IV contrast

Variant 4:Adult. Chronic ankle pain. Suspected tarsal coalition. Radiographs performed. Next imaging study.
C. CT ankle without and with IV contrast

Variant 4:Adult. Chronic ankle pain. Suspected tarsal coalition. Radiographs performed. Next imaging study.
D. CT ankle without IV contrast

Variant 4:Adult. Chronic ankle pain. Suspected tarsal coalition. Radiographs performed. Next imaging study.
E. CT arthrography ankle

Variant 4:Adult. Chronic ankle pain. Suspected tarsal coalition. Radiographs performed. Next imaging study.
F. MR arthrography ankle

Variant 4:Adult. Chronic ankle pain. Suspected tarsal coalition. Radiographs performed. Next imaging study.
G. MRI ankle without and with IV contrast

Variant 4:Adult. Chronic ankle pain. Suspected tarsal coalition. Radiographs performed. Next imaging study.
H. MRI ankle without IV contrast

Variant 4:Adult. Chronic ankle pain. Suspected tarsal coalition. Radiographs performed. Next imaging study.
I. US ankle

Variant 5:Adult. Chronic ankle pain. Suspected instability or ligamentous injury. Radiographs performed. Next imaging study.

Variant 5:Adult. Chronic ankle pain. Suspected instability or ligamentous injury. Radiographs performed. Next imaging study.
A. Bone scan ankle

Variant 5:Adult. Chronic ankle pain. Suspected instability or ligamentous injury. Radiographs performed. Next imaging study.
B. CT ankle with IV contrast

Variant 5:Adult. Chronic ankle pain. Suspected instability or ligamentous injury. Radiographs performed. Next imaging study.
C. CT ankle without and with IV contrast

Variant 5:Adult. Chronic ankle pain. Suspected instability or ligamentous injury. Radiographs performed. Next imaging study.
D. CT ankle without IV contrast

Variant 5:Adult. Chronic ankle pain. Suspected instability or ligamentous injury. Radiographs performed. Next imaging study.
E. CT arthrography ankle

Variant 5:Adult. Chronic ankle pain. Suspected instability or ligamentous injury. Radiographs performed. Next imaging study.
F. MR arthrography ankle

Variant 5:Adult. Chronic ankle pain. Suspected instability or ligamentous injury. Radiographs performed. Next imaging study.
G. MRI ankle without and with IV contrast

Variant 5:Adult. Chronic ankle pain. Suspected instability or ligamentous injury. Radiographs performed. Next imaging study.
H. MRI ankle without IV contrast

Variant 5:Adult. Chronic ankle pain. Suspected instability or ligamentous injury. Radiographs performed. Next imaging study.
I. Radiography ankle stress views

Variant 5:Adult. Chronic ankle pain. Suspected instability or ligamentous injury. Radiographs performed. Next imaging study.
J. US ankle

Variant 6:Adult. Chronic ankle pain. Suspected tendon pathology. Radiographs performed. Next imaging study.

Variant 6:Adult. Chronic ankle pain. Suspected tendon pathology. Radiographs performed. Next imaging study.
A. Bone scan ankle

Variant 6:Adult. Chronic ankle pain. Suspected tendon pathology. Radiographs performed. Next imaging study.
B. CT ankle with IV contrast

Variant 6:Adult. Chronic ankle pain. Suspected tendon pathology. Radiographs performed. Next imaging study.
C. CT ankle without and with IV contrast

Variant 6:Adult. Chronic ankle pain. Suspected tendon pathology. Radiographs performed. Next imaging study.
D. CT ankle without IV contrast

Variant 6:Adult. Chronic ankle pain. Suspected tendon pathology. Radiographs performed. Next imaging study.
E. CT arthrography ankle

Variant 6:Adult. Chronic ankle pain. Suspected tendon pathology. Radiographs performed. Next imaging study.
F. MR arthrography ankle

Variant 6:Adult. Chronic ankle pain. Suspected tendon pathology. Radiographs performed. Next imaging study.
G. MRI ankle without and with IV contrast

Variant 6:Adult. Chronic ankle pain. Suspected tendon pathology. Radiographs performed. Next imaging study.
H. MRI ankle without IV contrast

Variant 6:Adult. Chronic ankle pain. Suspected tendon pathology. Radiographs performed. Next imaging study.
I. US ankle

Summary of Highlights

Supporting Documents

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Gender Equality and Inclusivity Clause

The ACR acknowledges the limitations in applying inclusive language when citing research studies that predates the use of the current understanding of language inclusive of diversity in sex, intersex, gender, and gender-diverse people. The data variables regarding sex and gender used in the cited literature will not be changed. However, this guideline will use the terminology and definitions as proposed by the National Institutes of Health.

Appropriateness Category Names and Definitions

Appropriateness Category Name	Appropriateness Rating	Appropriateness Category Definition
Usually Appropriate	7, 8, or 9	The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.
May Be Appropriate	4, 5, or 6	The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.
May Be Appropriate (Disagreement)	5	The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.
Usually Not Appropriate	1, 2, or 3	The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.

Relative Radiation Level Information

Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, because of both organ sensitivity and longer life expectancy (relevant to the long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared with those specified for adults (see Table below). Additional information regarding radiation dose assessment for imaging examinations can be found in the ACR Appropriateness Criteria^® Radiation Dose Assessment Introduction document.

Relative Radiation Level Designations
Relative Radiation Level*	Adult Effective Dose Estimate Range	Pediatric Effective Dose Estimate Range
O	0 mSv	0 mSv
☢	<0.1 mSv	<0.03 mSv
☢☢	0.1-1 mSv	0.03-0.3 mSv
☢☢☢	1-10 mSv	0.3-3 mSv
☢☢☢☢	10-30 mSv	3-10 mSv
☢☢☢☢☢	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 (e.g., region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as “Varies.”

References

1.	Murray C, Marshall M, Rathod T, Bowen CJ, Menz HB, Roddy E. Population prevalence and distribution of ankle pain and symptomatic radiographic ankle osteoarthritis in community dwelling older adults: A systematic review and cross-sectional study. [Review]. PLoS ONE [Electronic Resource]. 13(4):e0193662, 2018.PLoS ONE. 13(4):e0193662, 2018.
2.	Wilkinson VH, Rowbotham EL, Grainger AJ. Imaging in Foot and Ankle Arthritis. [Review]. Semin Musculoskelet Radiol. 20(2):167-74, 2016 Apr.
3.	Nishimura A, Senga Y, Fujikawa Y, et al. Prevalence and risk factors of ankle osteoarthritis in a population-based study. Journal of Foot & Ankle Surgery. 30(5):389-393, 2024 Jul.J Foot Ankle Surg. 30(5):389-393, 2024 Jul.
4.	Lateef S, Golightly YM, Renner JB, Jordan JM, Nelson AE. A Cross-sectional Analysis of Radiographic Ankle Osteoarthritis Frequency and Associated Factors: The Johnston County Osteoarthritis Project. Journal of Rheumatology. 44(4):499-504, 2017 04.J Rheumatol. 44(4):499-504, 2017 04.
5.	Berman Z, Tafur M, Ahmed SS, Huang BK, Chang EY. Ankle impingement syndromes: an imaging review. [Review]. Br J Radiol. 90(1070):20160735, 2017 Feb.
6.	Barbier O. Osteochondral lesions of the talar dome. [Review]. Orthopaedics & traumatology, surgery & research. 109(1S):103452, 2023 02.Orthop Traumatol Surg Res. 109(1S):103452, 2023 02.
7.	Ellsworth BK, Kehoe C, DeFrancesco CJ, Bogner E, Mintz DN, Scher DM. Talocalcaneal Tarsal Coalition Size: Evaluation and Reproducibility of MRI Measurements. J Pediatr Orthop. 2022 Jul 01;42(6):e612-e615.
8.	Usuelli FG, Mason L, Grassi M, Maccario C, Ballal M, Molloy A. Lateral ankle and hindfoot instability: a new clinical based classification. [Review]. Journal of Foot & Ankle Surgery. 20(4):231-6, 2014 Dec.J Foot Ankle Surg. 20(4):231-6, 2014 Dec.
9.	Guillodo Y, Varache S, Saraux A. Value of ultrasonography for detecting ligament damage in athletes with chronic ankle instability compared to computed arthrotomography. Foot Ankle Spec. 2010 Dec;3(6):331-4.
10.	Takao M, Iwashita K, Miura T, et al. Ultrasound Imaging for the Evaluation of Anterior Talofibular Ligament Remnants in 547 Ankles With Chronic Lateral Ankle Instability. Foot & Ankle International. 45(12):1372-1379, 2024 Dec.Foot Ankle Int. 45(12):1372-1379, 2024 Dec.
11.	Subhas N, Wu F, Fox MG, et al. ACR Appropriateness Criteria® Chronic Extremity Joint Pain-Suspected Inflammatory Arthritis, Crystalline Arthritis, or Erosive Osteoarthritis: 2022 Update. J Am Coll Radiol 2023;20:S20-S32.
12.	Ahlawat S, Lenchik L, Baker JC, et al. ACR Appropriateness Criteria® Suspected Primary Bone Tumors: 2024 Update. J Am Coll Radiol 2025;22:S440-S54.
13.	Garner HW, Wessell DE, Lenchik L, et al. ACR Appropriateness Criteria® Soft Tissue Masses: 2022 Update. J Am Coll Radiol 2023;20:S234-S45.
14.	Ha AS, Chang EY, Bartolotta RJ, et al. ACR Appropriateness Criteria® Osteonecrosis: 2022 Update. J Am Coll Radiol 2022;19:S409-S16.
15.	Pierce JL, Perry MT, Wessell DE, et al. ACR Appropriateness Criteria® Suspected Osteomyelitis, Septic Arthritis, or Soft Tissue Infection (Excluding Spine and Diabetic Foot): 2022 Update. J Am Coll Radiol 2022;19:S473-S87.
16.	Tafur M, Bencardino JT, Roberts CC, et al. ACR Appropriateness Criteria® Chronic Foot Pain. J Am Coll Radiol 2020;17:S391-S402.
17.	Kloprogge SES, Lachmipersad RMMR, Katier NN, et al. Prognostic factors and the value of radiographic osteoarthritis for persistent complaints after referral for ankle radiography. Semin Arthritis Rheum. 2024 Oct;68():S0049-0172(24)00127-6.
18.	Dowling LB, Giakoumis M, Ryan JD. Narrowing the normal range for lateral ankle ligament stability with stress radiography. J Foot Ankle Surg. 53(3):269-73, 2014 May-Jun.
19.	Haug LP, Sill AP, Shrestha R, Patel KA, Kile TA, Fox MG. Osteochondral Lesions of the Ankle and Foot. Semin Musculoskelet Radiol. 2023 Jun;27(3):269-282.
20.	Hauger O, Moinard M, Lasalarie JC, Chauveaux D, Diard F. Anterolateral compartment of the ankle in the lateral impingement syndrome: appearance on CT arthrography. AJR. 1999;173(3):685-690.
21.	Fiorella D, Helms CA, Nunley JA, 2nd. The MR imaging features of the posterior intermalleolar ligament in patients with posterior impingement syndrome of the ankle. Skeletal Radiol. 1999;28(10):573-576.
22.	Jordan LK, 3rd, Helms CA, Cooperman AE, Speer KP. Magnetic resonance imaging findings in anterolateral impingement of the ankle. Skeletal Radiol. 2000;29(1):34-39.
23.	Bureau NJ, Cardinal E, Hobden R, Aubin B. Posterior ankle impingement syndrome: MR imaging findings in seven patients. Radiology. 2000 May;215(2):497-503.
24.	Robinson P, White LM, Salonen DC, Daniels TR, Ogilvie-Harris D. Anterolateral ankle impingement: mr arthrographic assessment of the anterolateral recess. Radiology. 2001 Oct;221(1):186-90.
25.	Robinson P, White LM, Salonen D, Ogilvie-Harris D. Anteromedial impingement of the ankle: using MR arthrography to assess the anteromedial recess. AJR Am J Roentgenol. 2002 Mar;178(3):601-4.
26.	Schaffler GJ, Tirman PF, Stoller DW, Genant HK, Ceballos C, Dillingham MF. Impingement syndrome of the ankle following supination external rotation trauma: MR imaging findings with arthroscopic correlation. Eur Radiol. 2003;13(6):1357-1362.
27.	Peace KA, Hillier JC, Hulme A, Healy JC. MRI features of posterior ankle impingement syndrome in ballet dancers: a review of 25 cases. Clin Radiol. 2004;59(11):1025-1033.
28.	Rubin DA, Tishkoff NW, Britton CA, Conti SF, Towers JD. Anterolateral soft-tissue impingement in the ankle: diagnosis using MR imaging. AJR. 1997;169(3):829-835.
29.	Farooki S, Yao L, Seeger LL. Anterolateral impingement of the ankle: effectiveness of MR imaging. Radiology. 1998;207(2):357-360.
30.	Aboelmagd SM, Low SB, Cahir JG, et al. The Norwich Osteoarthritis of the Ankle MRI Score (NOAMS): a reliability study. Clin Radiol. 2022 Jun;77(6):S0009-9260(22)00117-9.
31.	Duncan D, Mologne T, Hildebrand H, Stanley M, Schreckengaust R, Sitler D. The usefulness of magnetic resonance imaging in the diagnosis of anterolateral impingement of the ankle. J Foot Ankle Surg. 2006;45(5):304-307.
32.	Donovan A, Rosenberg ZS. MRI of ankle and lateral hindfoot impingement syndromes. [Review] [74 refs]. AJR Am J Roentgenol. 195(3):595-604, 2010 Sep.
33.	Russo A, Zappia M, Reginelli A, et al. Ankle impingement: a review of multimodality imaging approach. Musculoskelet Surg. 2013 Aug;97 Suppl 2():S161-8.
34.	Hayashi D, Roemer FW, D'Hooghe P, Guermazi A. Posterior ankle impingement in athletes: Pathogenesis, imaging features and differential diagnoses. Eur J Radiol. 2015 Nov;84(11):S0720-048X(15)30058-9.
35.	Berberian WS, Hecht PJ, Wapner KL, DiVerniero R. Morphology of tibiotalar osteophytes in anterior ankle impingement. Foot Ankle Int. 2001 Apr;22(4):313-7.
36.	de Carvalho KAM, Barbachan Mansur NS, de Cesar Netto C. Cone-Beam Weight-Bearing Computed Tomography of Ankle Arthritis and Total Ankle Arthroplasty. Foot Ankle Clin. 2023 Sep;28(3):S1083-7515(23)00060-8.
37.	Arena CB, Sripanich Y, Leake R, Saltzman CL, Barg A. Assessment of Hindfoot Alignment Comparing Weightbearing Radiography to Weightbearing Computed Tomography. Foot Ankle Int. 2021 Nov;42(11):1482-1490.
38.	Cochet H, Pele E, Amoretti N, Brunot S, Lafenetre O, Hauger O. Anterolateral ankle impingement: diagnostic performance of MDCT arthrography and sonography. AJR Am J Roentgenol. 194(6):1575-80, 2010 Jun.
39.	McCarthy CL, Wilson DJ, Coltman TP. Anterolateral ankle impingement: findings and diagnostic accuracy with ultrasound imaging. Skeletal Radiol. 37(3):209-16, 2008 Mar.
40.	Cerezal L, Llopis E, Canga A, Rolón A. MR arthrography of the ankle: indications and technique. Radiol Clin North Am. 2008 Nov;46(6):973-94, v.
41.	Huh YM, Suh JS, Lee JW, Song HT. Synovitis and soft tissue impingement of the ankle: assessment with enhanced three-dimensional FSPGR MR imaging. J Magn Reson Imaging. 2004;19(1):108-116.
42.	Bui-Mansfield LT, Kline M, Chew FS, Rogers LF, Lenchik L. Osteochondritis dissecans of the tibial plafond: imaging characteristics and a review of the literature. AJR Am J Roentgenol. 2000 Nov;175(5):1305-8.
43.	Bui-Mansfield LT, Lenchik L, Rogers LF, Chew FS, Boles CA, Kline M. Osteochondritis dissecans of the tarsal navicular bone: imaging findings in four patients. J Comput Assist Tomogr. 2000;24(5):744-747.
44.	Verhagen RA, Maas M, Dijkgraaf MG, Tol JL, Krips R, van Dijk CN. Prospective study on diagnostic strategies in osteochondral lesions of the talus. Is MRI superior to helical CT? J Bone Joint Surg Br. 2005;87(1):41-46.
45.	Posadzy M, Desimpel J, Vanhoenacker F. Staging of Osteochondral Lesions of the Talus: MRI and Cone Beam CT. J Belg Soc Radiol. 2017 Dec 16;101(Suppl 2):1.
46.	Lee KB, Bai LB, Park JG, Yoon TR. A comparison of arthroscopic and MRI findings in staging of osteochondral lesions of the talus. Knee Surg Sports Traumatol Arthrosc. 2008;16(11):1047-1051.
47.	Mintz DN, Tashjian GS, Connell DA, Deland JT, O'Malley M, Potter HG. Osteochondral lesions of the talus: a new magnetic resonance grading system with arthroscopic correlation. Arthroscopy. 2003 Apr;19(4):353-9.
48.	Kirschke JS, Braun S, Baum T, et al. Diagnostic Value of CT Arthrography for Evaluation of Osteochondral Lesions at the Ankle. Biomed Res Int. 2016;2016():3594253.
49.	Kim DY, Yoon JM, Park GY, Kang HW, Lee DO, Lee DY. Computed tomography arthrography versus magnetic resonance imaging for diagnosis of osteochondral lesions of the talus. Arch Orthop Trauma Surg. 2023 Sep;143(9):5631-5639.
50.	Schmid MR, Pfirrmann CW, Hodler J, Vienne P, Zanetti M. Cartilage lesions in the ankle joint: comparison of MR arthrography and CT arthrography. Skeletal Radiol. 2003 May;32(5):259-65.
51.	Meftah M, Katchis SD, Scharf SC, Mintz DN, Klein DA, Weiner LS. SPECT/CT in the management of osteochondral lesions of the talus. Foot Ankle Int. 2011;32(3):233-238.
52.	Marth AA, Feuerriegel GC, Marcus RP, Sutter R. How accurate is MRI for diagnosing tarsal coalitions? A retrospective diagnostic accuracy study. Eur Radiol. 2024 May;34(5):3493-3502.
53.	Mehdi N, Bernasconi A, Lintz F. Tarsal coalition in adults. [Review]. Orthopaedics & traumatology, surgery & research. 110(1S):103761, 2024 Feb.Orthop Traumatol Surg Res. 110(1S):103761, 2024 Feb.
54.	Emery KH, Bisset GS, Johnson ND, Nunan PJ. Tarsal coalition: a blinded comparison of MRI and CT. Pediatr Radiol. 1998 Aug;28(8):612-6.
55.	Catanzano AA, Akoh CC, Easley ME, Mosca VS. Decision-Making and Management of Tarsal Coalition in the Young Adult Patient: A Critical Analysis Review. JBJS Rev. 2023 Jun 01;11(6).
56.	Lee KT, Park YU, Jegal H, Park JW, Choi JP, Kim JS. New method of diagnosis for chronic ankle instability: comparison of manual anterior drawer test, stress radiography and stress ultrasound. Knee Surg Sports Traumatol Arthrosc. 2014 Jul;22(7):1701-7.
57.	Oae K, Takao M, Uchio Y, Ochi M. Evaluation of anterior talofibular ligament injury with stress radiography, ultrasonography and MR imaging. Skeletal Radiol. 2010;39(1):41-47.
58.	Joshy S, Abdulkadir U, Chaganti S, Sullivan B, Hariharan K. Accuracy of MRI scan in the diagnosis of ligamentous and chondral pathology in the ankle. Foot Ankle Surg. 2010;16(2):78-80.
59.	Park HJ, Cha SD, Kim SS, et al. Accuracy of MRI findings in chronic lateral ankle ligament injury: comparison with surgical findings. Clin Radiol. 2012;67(4):313-318.
60.	Crim J, Longenecker LG. MRI and surgical findings in deltoid ligament tears. AJR Am J Roentgenol. 204(1):W63-9, 2015 Jan.
61.	Oae K, Takao M, Naito K, et al. Injury of the tibiofibular syndesmosis: value of MR imaging for diagnosis. Radiology. 2003 Apr;227(1):155-61.
62.	Nielson JH, Sallis JG, Potter HG, Helfet DL, Lorich DG. Correlation of interosseous membrane tears to the level of the fibular fracture. J Orthop Trauma. 2004;18(2):68-74.
63.	DiGiovanni BF, Fraga CJ, Cohen BE, Shereff MJ. Associated injuries found in chronic lateral ankle instability. Foot Ankle Int. 2000;21(10):809-815.
64.	Chien AJ, Jacobson JA, Jamadar DA, Brigido MK, Femino JE, Hayes CW. Imaging appearances of lateral ankle ligament reconstruction. Radiographics. 2004;24(4):999-1008.
65.	Elkaïm M, Thès A, Lopes R, et al. Agreement between arthroscopic and imaging study findings in chronic anterior talo-fibular ligament injuries. Orthop Traumatol Surg Res. 2018 Dec;104(8S):S1877-0568(18)30264-0.
66.	Christodoulou G, Korovessis P, Giarmenitis S, Dimopoulos P, Sdougos G. The use of sonography for evaluation of the integrity and healing process of the tibiofibular interosseous membrane in ankle fractures. J Orthop Trauma. 1995;9(2):98-106.
67.	Cho JH, Lee DH, Song HK, Bang JY, Lee KT, Park YU. Value of stress ultrasound for the diagnosis of chronic ankle instability compared to manual anterior drawer test, stress radiography, magnetic resonance imaging, and arthroscopy. Knee Surg Sports Traumatol Arthrosc. 24(4):1022-8, 2016 Apr.
68.	Tourne Y, Besse JL, Mabit C. Chronic ankle instability. Which tests to assess the lesions? Which therapeutic options? Orthop Traumatol Surg Res. 2010;96(4):433-446.
69.	Hoffman E, Paller D, Koruprolu S, et al. Accuracy of plain radiographs versus 3D analysis of ankle stress test. Foot Ankle Int. 2011;32(10):994-999.
70.	Lee BH, Choi KH, Seo DY, Choi SM, Kim GL. Diagnostic validity of alternative manual stress radiographic technique detecting subtalar instability with concomitant ankle instability. Knee Surg Sports Traumatol Arthrosc. 2016 Apr;24(4):1029-39.
71.	Lepojarvi S, Niinimaki J, Pakarinen H, Leskela HV. Rotational Dynamics of the Normal Distal Tibiofibular Joint With Weight-Bearing Computed Tomography. Foot Ankle Int. 37(6):627-35, 2016 Jun.
72.	Burssens A, Vermue H, Barg A, Krähenbühl N, Victor J, Buedts K. Templating of Syndesmotic Ankle Lesions by Use of 3D Analysis in Weightbearing and Nonweightbearing CT. Foot Ankle Int. 2018 Dec;39(12):1487-1496.
73.	Hagemeijer NC, Chang SH, Abdelaziz ME, et al. Range of Normal and Abnormal Syndesmotic Measurements Using Weightbearing CT. Foot Ankle Int. 2019 Dec;40(12):1430-1437.
74.	Bhimani R, Ashkani-Esfahani S, Lubberts B, et al. Utility of Volumetric Measurement via Weight-Bearing Computed Tomography Scan to Diagnose Syndesmotic Instability. Foot Ankle Int. 2020 Jul;41(7):859-865.
75.	Bhimani R, Ashkani-Esfahani S, Lubberts B, et al. Utility of WBCT to Diagnose Syndesmotic Instability in Patients With Weber B Lateral Malleolar Fractures. J Am Acad Orthop Surg. 2022 Feb 01;30(3):e423-e433.
76.	Lee SJ, Jacobson JA, Kim SM, et al. Ultrasound and MRI of the peroneal tendons and associated pathology. [Review]. Skeletal Radiol. 42(9):1191-200, 2013 Sep.
77.	Ng JM, Rosenberg ZS, Bencardino JT, Restrepo-Velez Z, Ciavarra GA, Adler RS. US and MR imaging of the extensor compartment of the ankle. Radiographics. 33(7):2047-64, 2013 Nov-Dec.
78.	Waitches GM, Rockett M, Brage M, Sudakoff G. Ultrasonographic-surgical correlation of ankle tendon tears. J Ultrasound Med. 1998;17(4):249-256.
79.	Nallamshetty L, Nazarian LN, Schweitzer ME, et al. Evaluation of posterior tibial pathology: comparison of sonography and MR imaging. Skeletal Radiol. 2005;34(7):375-380.
80.	Grant TH, Kelikian AS, Jereb SE, McCarthy RJ. Ultrasound diagnosis of peroneal tendon tears. A surgical correlation. J Bone Joint Surg Am. 2005;87(8):1788-1794.
81.	Astrom M, Gentz CF, Nilsson P, Rausing A, Sjoberg S, Westlin N. Imaging in chronic achilles tendinopathy: a comparison of ultrasonography, magnetic resonance imaging and surgical findings in 27 histologically verified cases. Skeletal Radiol. 1996;25(7):615-620.
82.	Hartgerink P, Fessell DP, Jacobson JA, van Holsbeeck MT. Full- versus partial-thickness Achilles tendon tears: sonographic accuracy and characterization in 26 cases with surgical correlation. Radiology. 2001;220(2):406-412.
83.	Rosenberg ZS, Cheung Y, Jahss MH, Noto AM, Norman A, Leeds NE. Rupture of posterior tibial tendon: CT and MR imaging with surgical correlation. Radiology. 1988;169(1):229-235.
84.	Park HJ, Cha SD, Kim HS, et al. Reliability of MRI findings of peroneal tendinopathy in patients with lateral chronic ankle instability. Clin Orthop Surg. 2010;2(4):237-243.
85.	Saxena A, Luhadiya A, Ewen B, Goumas C. Magnetic resonance imaging and incidental findings of lateral ankle pathologic features with asymptomatic ankles. J Foot Ankle Surg. 50(4):413-5, 2011 Jul-Aug.
86.	Roth JA, Taylor WC, Whalen J. Peroneal tendon subluxation: the other lateral ankle injury. Br J Sports Med. 2010;44(14):1047-1053.

Disclaimer

The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.