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Appropriateness Criteria

Variant 1: Chronic ankle pain. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography ankle Usually appropriate Limited ☢ <0.1 mSv ☢ <0.03 mSv [ped] 9 9 0 0 0 0 0 0 0 0 0
References Study Quality
19 (15378290) 2
20 (26606603) 3
US ankle Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 0 0 0 0 0 0 0 0 0
MRI ankle without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 0 0 0 0 0 0 0 0 0
MRI ankle without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 0 0 0 0 0 0 0 0 0
CT ankle with IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 0 0 0 0 0 0 0 0 0
CT ankle without and with IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 0 0 0 0 0 0 0 0 0
CT ankle without IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 0 0 0 0 0 0 0 0 0
Bone scan ankle Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 0 0 0 0 0 0 0 0 0
Variant 2: Chronic ankle pain. Multiple sites of degenerative joint disease in the hindfoot detected by ankle radiographs. Next study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Image-guided anesthetic injection ankle and hindfoot May be appropriate Limited Varies Varies 6 6 0 0 0 0 0 0 0 0 0
References Study Quality
23 (27468671) 4
24 (19321101) 3
25 (25542943) 3
11 (23487336) 4
21 (8751679) 4
22 (9240528) 4
MRI ankle and hindfoot without IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 0 0 0 0 0 0 0 0
References Study Quality
13 (11870444) 4
14 (20483139) 3
15 (19685050) 3
CT ankle and hindfoot without IV contrast May be appropriate Limited ☢ <0.1 mSv 4 4 0 0 0 0 0 0 0 0 0
References Study Quality
5 (15686236) 2
US ankle and hindfoot Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 0 0 0 0 0 0 0 0 0
Radiographic arthrography ankle and hindfoot Usually not appropriate Expert Consensus ☢ <0.1 mSv 1 1 0 0 0 0 0 0 0 0 0
MR arthrography ankle and hindfoot Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 0 0 0 0 0 0 0 0 0
MRI ankle and hindfoot without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 0 0 0 0 0 0 0 0 0
References Study Quality
13 (11870444) 4
14 (20483139) 3
15 (19685050) 3
CT ankle and hindfoot with IV contrast Usually not appropriate Limited ☢ <0.1 mSv 1 1 0 0 0 0 0 0 0 0 0
References Study Quality
5 (15686236) 2
CT ankle and hindfoot without and with IV contrast Usually not appropriate Limited ☢ <0.1 mSv 1 1 0 0 0 0 0 0 0 0 0
References Study Quality
5 (15686236) 2
CT arthrography ankle and hindfoot Usually not appropriate Expert Consensus ☢ <0.1 mSv 1 1 0 0 0 0 0 0 0 0 0
Bone scan hindfoot/ankle Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 0 0 0 0 0 0 0 0 0
Variant 3: Chronic ankle pain. Ankle radiographs normal, suspected osteochondral lesion. Next study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI ankle without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 0 0 0
References Study Quality
28 (8848747) 3
30 (18635628) 4
29 (18779951) 3
31 (21826613) 4
5 (15686236) 2
6 (12682790) 2
MR arthrography ankle May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 0 0 0 0 0 0 0 0 0
References Study Quality
6 (12682790) 2
CT ankle without IV contrast May be appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 4 4 0 0 0 0 0 0 0 0 0
References Study Quality
5 (15686236) 2
CT arthrography ankle May be appropriate Limited ☢ <0.1 mSv 6 6 0 0 0 0 0 0 0 0 0
References Study Quality
6 (12682790) 2
Bone scan with SPECT or SPECT/CT ankle May be appropriate (Disagreement) Expert Opinion ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 4 1 1 4 4 3 0 0 0
References Study Quality
32 (21300809) 3
33 (21477540) 2
34 (25920051) 3
8 (21321364) 3
US ankle Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 0 0 0 0 0 0 0 0 0
Radiographic arthrography ankle Usually not appropriate Expert Consensus ☢ <0.1 mSv 1 1 0 0 0 0 0 0 0 0 0
Radiography ankle stress views Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢ <0.03 mSv [ped] 1 1 0 0 0 0 0 0 0 0 0
Image-guided anesthetic injection ankle Usually not appropriate Expert Consensus Varies Varies 3 3 8 0 1 3 4 1 0 0 0
MRI ankle without and with IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 1 1 0 0 0 0 0 0 0 0 0
References Study Quality
28 (8848747) 3
30 (18635628) 4
29 (18779951) 3
31 (21826613) 4
5 (15686236) 2
6 (12682790) 2
CT ankle with IV contrast Usually not appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 0 0 0 0 0 0 0 0 0
References Study Quality
5 (15686236) 2
CT ankle without and with IV contrast Usually not appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 0 0 0 0 0 0 0 0 0
References Study Quality
5 (15686236) 2
Variant 4: Chronic ankle pain. Ankle radiographs normal or nonspecific, suspected tendon abnormality. Next study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US ankle Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 0 0 0 0 0
References Study Quality
36 (9544608) 3
37 (15895226) 3
38 (16085620) 3
45 (19945971) 4
39 (8915043) 3
40 (11477244) 3
44 (15385290) 3
41 (26235856) 2
42 (22338951) 2
43 (25448138) 2
35 (24224598) 4
10 (23685674) 4
11 (23487336) 4
MRI ankle without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 0 0 0
References Study Quality
37 (15895226) 3
48 (21119941) 3
45 (19945971) 4
39 (8915043) 3
44 (15385290) 3
49 (21570324) 4
50 (23966263) 3
16 (3420263) 3
US-guided anesthetic injection ankle tendon sheath May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 0 0 0 0 0 0 0 0 0
References Study Quality
11 (23487336) 4
Fluoroscopy tenography ankle Usually not appropriate Limited ☢ <0.1 mSv 1 1 0 0 0 0 0 0 0 0 0
References Study Quality
51 (11159075) 4
Radiographic arthrography ankle Usually not appropriate Expert Consensus ☢ <0.1 mSv 1 1 0 0 0 0 0 0 0 0 0
Radiography ankle stress views Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢ <0.03 mSv [ped] 1 1 0 0 0 0 0 0 0 0 0
MR arthrography ankle Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 0 0 0 0 0 0 0 0 0
MRI ankle without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 0 0 0 0 0 0 0 0 0
References Study Quality
37 (15895226) 3
48 (21119941) 3
45 (19945971) 4
39 (8915043) 3
44 (15385290) 3
49 (21570324) 4
50 (23966263) 3
16 (3420263) 3
CT ankle with IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 0 0 0 0 0 0 0 0 0
CT ankle without and with IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 0 0 0 0 0 0 0 0 0
CT ankle without IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 0 0 0 0 0 0 0 0 0
CT arthrography ankle Usually not appropriate Expert Consensus ☢ <0.1 mSv 1 1 0 0 0 0 0 0 0 0 0
Bone scan ankle Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 0 0 0 0 0 0 0 0 0
Variant 5: Chronic ankle pain. Ankle radiographs normal or nonspecific, suspected ankle instability. Next study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MR arthrography ankle Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 0 0 0 0 0
References Study Quality
12 (23622094) 4
MRI ankle without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 0 0 0
References Study Quality
57 (15256624) 4
54 (12616009) 3
55 (14743024) 3
56 (11128010) 4
53 (25539277) 3
52 (22078461) 3
14 (20483139) 3
15 (19685050) 3
US ankle May be appropriate Strong O 0 mSv O 0 mSv [ped] 6 6 0 0 0 0 0 0 0 0 0
References Study Quality
58 (20817846) 3
60 (7776043) 2
1 (26515772) 3
59 (24067992) 3
15 (19685050) 3
Radiography ankle stress views May be appropriate Strong ☢ <0.1 mSv ☢ <0.03 mSv [ped] 6 6 0 0 0 0 4 6 3 4 0
References Study Quality
1 (26515772) 3
2 (24560546) 3
61 (26869035) 2
3 (22224329) 3
4 (20493798) 4
15 (19685050) 3
CT arthrography ankle May be appropriate Limited ☢ <0.1 mSv 5 5 0 0 0 0 0 0 0 0 0
References Study Quality
58 (20817846) 3
Radiographic arthrography ankle Usually not appropriate Expert Consensus ☢ <0.1 mSv 1 1 0 0 0 0 0 0 0 0 0
Image-guided anesthetic injection ankle Usually not appropriate Expert Consensus Varies Varies 1 1 0 0 0 0 0 0 0 0 0
MRI ankle without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 0 0 0 0 0 0 0 0 0
References Study Quality
57 (15256624) 4
54 (12616009) 3
55 (14743024) 3
56 (11128010) 4
53 (25539277) 3
52 (22078461) 3
14 (20483139) 3
15 (19685050) 3
CT ankle with IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 0 0 0 0 0 0 0 0 0
CT ankle without and with IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 0 0 0 0 0 0 0 0 0
CT ankle without IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 0 0 0 0 0 0 0 0 0
Bone scan ankle Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 0 0 0 0 0 0 0 0 0
Variant 6: Chronic ankle pain. Ankle radiographs normal or nonspecific, suspected ankle impingement syndrome. Next study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI ankle without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 1 0 2 2 2 1 8
References Study Quality
73 (16949527) 3
68 (11856682) 4
64 (10550534) 4
67 (15488852) 4
76 (20729435) 4
62 (10796931) 4
75 (14696227) 2
74 (20727312) 3
US ankle May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 0 0 0 0 0 0 0 0
References Study Quality
70 (9275907) 3
72 (18064426) 3
Image-guided anesthetic injection ankle May be appropriate (Disagreement) Expert Opinion Varies Varies 5 5 0 3 3 4 4 1 0 2 0
References Study Quality
78 (16362423) 4
79 (10847526) 3
MR arthrography ankle May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 0 0 0 0 0 0 0 0 0
References Study Quality
69 (11568338) 2
68 (11856682) 4
CT ankle without IV contrast May be appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 5 5 0 0 0 2 10 2 2 1 0
References Study Quality
62 (10796931) 4
CT arthrography ankle May be appropriate Limited ☢ <0.1 mSv 5 5 0 0 0 0 0 0 0 0 0
References Study Quality
77 (20489099) 2
Radiographic arthrography ankle Usually not appropriate Expert Consensus ☢ <0.1 mSv 1 1 0 0 0 0 0 0 0 0 0
Radiography ankle stress views Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢ <0.03 mSv [ped] 1 1 0 0 0 0 0 0 0 0 0
MRI ankle without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 8 3 4 2 0 0 0 0 0
References Study Quality
73 (16949527) 3
68 (11856682) 4
64 (10550534) 4
67 (15488852) 4
76 (20729435) 4
62 (10796931) 4
75 (14696227) 2
74 (20727312) 3
CT ankle with IV contrast Usually not appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 14 2 0 0 0 0 0 0 0
References Study Quality
62 (10796931) 4
CT ankle without and with IV contrast Usually not appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 14 0 2 0 0 0 0 0 0
References Study Quality
62 (10796931) 4
3-phase bone scan with SPECT or SPECT/CT ankle Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 8 2 0 3 3 0 0 0 0
References Study Quality
7 (23211997) 3
Variant 7: Chronic ankle pain. Ankle radiographs normal, pain of uncertain etiology. Next study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI ankle without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 0 0 0
References Study Quality
82 (17015602) 3
80 (21343690) 4
81 (17099238) 4
13 (11870444) 4
US ankle May be appropriate Limited O 0 mSv O 0 mSv [ped] 4 4 5 2 0 6 3 0 0 0 1
References Study Quality
84 (18451390) 4
83 (17179329) 4
Image-guided anesthetic injection ankle May be appropriate Strong Varies Varies 4 4 5 1 1 2 5 1 1 0 0
References Study Quality
87 (21941219) 3
88 (19587626) 1
89 (19258984) 1
CT ankle without IV contrast May be appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 5 5 0 0 0 0 11 4 2 0 0
References Study Quality
85 (15333345) 3
80 (21343690) 4
Bone scan with SPECT or SPECT/CT ankle May be appropriate (Disagreement) Expert Opinion ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 2 3 3 2 4 3 0 0 0
References Study Quality
86 (21540716) 4
Radiographic arthrography ankle Usually not appropriate Expert Consensus ☢ <0.1 mSv 1 1 0 0 0 0 0 0 0 0 0
Radiography ankle stress views Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢ <0.03 mSv [ped] 1 1 0 0 0 0 0 0 0 0 0
MR arthrography ankle Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 0 0 0 0 0 0 0 0 0
MRI ankle without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 0 0 0 0 0 0 0 0 0
References Study Quality
82 (17015602) 3
80 (21343690) 4
81 (17099238) 4
13 (11870444) 4
CT ankle with IV contrast Usually not appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 16 0 0 0 0 0 0 0 0
References Study Quality
85 (15333345) 3
80 (21343690) 4
CT ankle without and with IV contrast Usually not appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 16 0 0 0 0 0 0 0 0
References Study Quality
85 (15333345) 3
80 (21343690) 4
CT arthrography ankle Usually not appropriate Expert Consensus ☢ <0.1 mSv 1 1 0 0 0 0 0 0 0 0 0
Appendix Key

A more complete discussion of the items presented below can be found by accessing the supporting documents at the designated hyperlinks.

Appropriateness Category:The panel’s recommendation for a procedure based on the assessment of the risks and benefits of performing the procedure for the specified clinical scenario.

SOE: Strength of Evidence. The assessment of the amount and quality of evidence found in the peer reviewed medical literature for an appropriateness recommendation.

  • References: The citation number and PMID for the reference(s) associated with the recommendation.
  • Study Quality: The assessment of the quality of an individual reference based on the number of study quality elements described in the reference.

RRL: Relative Radiation Level. A population based assessment of the amount of radiation a typical patient may be exposed to during the specified procedure.

Rating: The final rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Median: The median rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Final tabulations: A histogram showing the number of panel members who rated the procedure as noted in the column heading (ie, 1, 2, 3, etc.).

Additional supporting documents about the AC methodology and processes can be found at www.acr.org/ac.