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Appropriateness Criteria

Variant 1: Adult. 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 1 0 0 0 0 0 0 0 10
References Study Quality
56 (24067992) 3
18 (24560546) 3
US ankle Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 8 1 1 0 0 0 1 0 0
References Study Quality
38 (20489099) 2
39 (18064426) 3
79 (15895226) 3
56 (24067992) 3
MRI ankle without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 9 0 1 1 0 0 0 0 0
References Study Quality
79 (15895226) 3
84 (21119941) 3
32 (20729435) 4
67 (26515772) 3
50 (12682790) 2
MRI ankle without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 8 1 1 1 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 9 0 1 1 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 9 0 1 1 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 6 1 2 2 0 0 0 0 0
Bone scan ankle Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 9 0 2 0 0 0 0 0 0
Variant 2: Adult. Chronic ankle pain. Suspected osteoarthritis or early impingement. Radiographs performed. Next imaging 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] 8 8 0 0 0 0 0 3 1 2 5
CT ankle without IV contrast Usually appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 7 7 0 0 0 0 0 1 6 4 0
US ankle Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 6 0 2 1 1 0 1 0 0
References Study Quality
39 (18064426) 3
79 (15895226) 3
56 (24067992) 3
MR arthrography ankle Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 7 0 1 1 1 1 0 0 0
MRI ankle without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 7 1 1 1 1 0 0 0 0
References Study Quality
79 (15895226) 3
84 (21119941) 3
32 (20729435) 4
67 (26515772) 3
50 (12682790) 2
CT ankle with IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 9 0 1 1 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 9 0 1 1 0 0 0 0 0
CT arthrography ankle Usually not appropriate Limited ☢ <0.1 mSv 1 1 7 0 0 3 0 1 0 0 0
Bone scan ankle Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 9 0 2 0 0 0 0 0 0
References Study Quality
51 (21477540) 2
Variant 3: Adult. Chronic ankle pain. Suspected osteochondral lesion. Radiographs performed. Next imaging 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 2 1 8
CT ankle without IV contrast Usually appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 7 7 0 0 0 0 1 4 6 0 0
CT arthrography ankle May be appropriate Limited ☢ <0.1 mSv 5 5 1 0 0 2 4 1 2 1 0
US ankle Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 9 0 1 0 0 0 1 0 0
References Study Quality
39 (18064426) 3
56 (24067992) 3
MR arthrography ankle Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 1 1 8 0 1 0 1 1 0 0 0
MRI ankle without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 8 0 0 2 1 0 0 0 0
References Study Quality
67 (26515772) 3
50 (12682790) 2
CT ankle with IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 9 0 1 0 1 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 9 0 1 0 1 0 0 0 0
Bone scan ankle Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 8 0 2 1 0 0 0 0 0
References Study Quality
51 (21477540) 2
Variant 4: Adult. Chronic ankle pain. Suspected tarsal coalition. Radiographs performed. Next imaging 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 0 0 1 3 6
CT ankle without IV contrast Usually appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 9 9 0 0 1 0 2 0 0 2 6
US ankle Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 9 0 1 0 0 1 0 0 0
References Study Quality
39 (18064426) 3
56 (24067992) 3
MR arthrography ankle Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 8 1 1 1 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 8 1 1 1 0 0 0 0 0
References Study Quality
32 (20729435) 4
67 (26515772) 3
50 (12682790) 2
CT ankle with IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 9 0 1 1 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 9 0 1 1 0 0 0 0 0
CT arthrography ankle Usually not appropriate Expert Consensus ☢ <0.1 mSv 1 1 8 1 1 1 0 0 0 0 0
Bone scan ankle Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 8 1 2 0 0 0 0 0 0
Variant 5: Adult. Chronic ankle pain. Suspected instability or ligamentous injury. Radiographs performed. Next imaging 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 1 0 0 0 2 8
US ankle May be appropriate Strong O 0 mSv O 0 mSv [ped] 5 5 0 1 0 1 8 1 0 0 0
References Study Quality
39 (18064426) 3
56 (24067992) 3
Radiography ankle stress views May be appropriate Strong ☢ <0.1 mSv ☢ <0.03 mSv [ped] 6 6 0 0 0 1 2 3 1 3 1
References Study Quality
56 (24067992) 3
MR arthrography ankle Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 9 1 1 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 7 1 1 1 1 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 8 1 1 1 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 8 1 1 1 0 0 0 0 0
CT ankle without IV contrast Usually not appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 2 2 5 2 1 1 2 0 0 0 0
CT arthrography ankle Usually not appropriate Moderate ☢ <0.1 mSv 1 1 6 1 0 3 0 1 0 0 0
Bone scan ankle Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 9 0 2 0 0 0 0 0 0
Variant 6: Adult. Chronic ankle pain. Suspected tendon pathology. Radiographs performed. Next imaging 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 Limited O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 0 2 3 3 3
References Study Quality
39 (18064426) 3
MRI ankle without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 1 0 0 0 2 8
MR arthrography ankle Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 7 0 1 3 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 8 0 0 1 2 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 9 0 1 1 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 9 0 1 1 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 8 0 1 1 1 0 0 0 0
CT arthrography ankle Usually not appropriate Expert Consensus ☢ <0.1 mSv 1 1 7 0 1 2 1 0 0 0 0
Bone scan ankle Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 9 0 2 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.