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Appropriateness Criteria

Variant 1: Chronic elbow 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 elbow Usually appropriate Limited ☢ <0.1 mSv 9 9 0 0 0 0 0 0 0 1 13
References Study Quality
5 (11940640) 4
7 (9617407) 4
4 (12783223) 3
6 (32305107) 4
US elbow Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 9 0 2 1 2 0 0 0 0
MR arthrography elbow Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 0 0 0 1 0 0 0 0
MRI elbow without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 0 0 0 1 0 0 0 0
MRI elbow without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 0 0 1 2 0 0 0 0
CT arthrography elbow Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 1 1 13 0 1 0 0 0 0 0 0
CT elbow with IV contrast Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 1 1 13 0 1 0 0 0 0 0 0
CT elbow without and with IV contrast Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 1 1 13 0 0 0 1 0 0 0 0
CT elbow without IV contrast Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 1 1 11 0 1 0 2 0 0 0 0
3-phase bone scan elbow Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 14 0 0 0 0 0 0 0 0
Variant 2: Chronic elbow pain with mechanical symptoms such as locking, clicking, or limited range of motion. Suspect intra-articular pathology such as osteocartilaginous body, osteochondral lesion, or synovial abnormality. Radiographs normal or nonspecific. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MR arthrography elbow Usually appropriate Limited O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 3 1 2 4 4
References Study Quality
12 (8180456) 3
13 (10708607) 4
14 (12235350) 4
16 (22929044) 2
15 (30016689) 4
MRI elbow without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 1 4 9
References Study Quality
12 (8180456) 3
17 (8946538) 4
16 (22929044) 2
18 (11000172) 3
15 (30016689) 4
CT arthrography elbow Usually appropriate Limited ☢☢ 0.1-1mSv 7 7 0 0 0 1 1 3 3 3 3
References Study Quality
10 (20489071) 2
11 (16315115) 4
CT elbow without IV contrast Usually appropriate Limited ☢☢ 0.1-1mSv 8 8 0 0 0 0 3 1 2 5 3
References Study Quality
10 (20489071) 2
US elbow Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 5 1 4 1 2 1 0 0 0
References Study Quality
10 (20489071) 2
MRI elbow without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 14 0 0 0 0 0 0 0 0
References Study Quality
12 (8180456) 3
17 (8946538) 4
16 (22929044) 2
18 (11000172) 3
15 (30016689) 4
CT elbow with IV contrast Usually not appropriate Limited ☢☢ 0.1-1mSv 1 1 14 0 0 0 0 0 0 0 0
References Study Quality
10 (20489071) 2
CT elbow without and with IV contrast Usually not appropriate Limited ☢☢ 0.1-1mSv 1 1 14 0 0 0 0 0 0 0 0
References Study Quality
10 (20489071) 2
3-phase bone scan elbow Usually not appropriate Limited ☢☢☢ 1-10 mSv 1 1 13 1 0 0 0 0 0 0 0
References Study Quality
9 (11884494) 4
8 (6215609) 4
Variant 3: Chronic elbow pain. Suspect occult stress fracture or other bone abnormality. Radiographs normal or nonspecific. 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 elbow without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 1 0 13
References Study Quality
20 (16798139) 4
CT elbow without IV contrast Usually appropriate Limited ☢☢ 0.1-1mSv 8 8 0 0 0 0 4 2 1 4 3
References Study Quality
20 (16798139) 4
22 (15164781) 4
3-phase bone scan elbow May be appropriate (Disagreement) Expert Opinion ☢☢☢ 1-10 mSv 5 5 1 1 0 1 5 2 2 0 2
References Study Quality
20 (16798139) 4
21 (19668095) 3
19 (-3194390) 4
US elbow Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 9 0 3 0 1 0 0 1 0
References Study Quality
23 (18626636) 2
MR arthrography elbow Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 9 1 2 1 1 0 0 0 0
MRI elbow without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 9 0 1 0 3 1 0 0 0
References Study Quality
20 (16798139) 4
CT arthrography elbow Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 1 1 9 1 3 0 0 0 1 0 0
CT elbow with IV contrast Usually not appropriate Limited ☢☢ 0.1-1mSv 1 1 9 0 1 0 2 1 0 1 0
References Study Quality
20 (16798139) 4
22 (15164781) 4
CT elbow without and with IV contrast Usually not appropriate Limited ☢☢ 0.1-1mSv 1 1 9 0 1 0 3 0 0 1 0
References Study Quality
20 (16798139) 4
22 (15164781) 4
Variant 4: Chronic elbow pain. Suspect chronic epicondylalgia or tendon tear. Refractory to empirical treatment. Radiographs normal or nonspecific. 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 elbow Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 0 0 5 4 5
References Study Quality
35 (23255757) 3
33 (28850740) 2
34 (29177701) 3
31 (28749994) 2
32 (25189955) 3
MRI elbow without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 1 0 13
References Study Quality
28 (15711999) 4
30 (19942363) 3
27 (11981928) 1
29 (29027008) 3
26 (31040053) 2
MR arthrography elbow Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 8 1 0 3 1 1 0 0 0
References Study Quality
25 (11414155) 4
MRI elbow without and with IV contrast Usually not appropriate Moderate O 0 mSv O 0 mSv [ped] 1 1 13 1 0 0 0 0 0 0 0
References Study Quality
28 (15711999) 4
30 (19942363) 3
27 (11981928) 1
29 (29027008) 3
26 (31040053) 2
CT arthrography elbow Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 1 1 12 0 0 1 1 0 0 0 0
CT elbow with IV contrast Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 1 1 12 0 0 0 1 1 0 0 0
CT elbow without and with IV contrast Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 1 1 12 0 0 0 2 0 0 0 0
CT elbow without IV contrast Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 1 1 10 0 2 0 1 1 0 0 0
3-phase bone scan elbow Usually not appropriate Limited ☢☢☢ 1-10 mSv 1 1 9 1 3 0 1 0 0 0 0
References Study Quality
24 (18996248) 2
Variant 5: Chronic elbow pain. Suspect collateral ligament tear. Radiographs normal or nonspecific. 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 elbow Usually appropriate Limited O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 1 1 3 6 3
References Study Quality
47 (8956595) 4
46 (32067711) 2
36 (32735456) 4
MR arthrography elbow Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 1 0 1 12
References Study Quality
40 (15480640) 4
43 (9205244) 4
37 (7568841) 2
41 (9673644) 4
38 (25539278) 3
42 (30699009) 3
44 (26095056) 3
39 (27183408) 2
MRI elbow without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 8 8 0 0 0 1 1 2 2 3 5
References Study Quality
38 (25539278) 3
CT arthrography elbow Usually appropriate Limited ☢☢ 0.1-1mSv 8 8 0 0 0 0 1 1 5 3 4
References Study Quality
36 (32735456) 4
Radiography elbow stress views May be appropriate Limited ☢ <0.1 mSv 5 5 0 0 0 1 7 4 2 0 0
References Study Quality
45 (29322208) 3
6 (32305107) 4
MRI elbow without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 14 0 0 0 0 0 0 0 0
References Study Quality
38 (25539278) 3
CT elbow with IV contrast Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 1 1 12 0 0 1 0 1 0 0 0
CT elbow without and with IV contrast Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 1 1 12 0 0 1 0 1 0 0 0
CT elbow without IV contrast Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 1 1 11 1 0 0 1 1 0 0 0
3-phase bone scan elbow Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 13 0 0 0 1 0 0 0 0
Variant 6: Chronic elbow pain. Suspect nerve abnormality. Radiographs normal or nonspecific. 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 elbow Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 3 4 7
References Study Quality
61 (15179657) 3
60 (11526255) 4
48 (28842238) 2
56 (28888384) Good
62 (28987654) 4
57 (31137210) 3
59 (31568902) 3
63 (29858636) 1
58 (30130723) 3
64 (30245016) 3
MRI elbow without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 1 3 10
References Study Quality
50 (21845447) 3
54 (8079837) 4
55 (15172385) 4
51 (16481216) 3
47 (8956595) 4
48 (28842238) 2
52 (29602661) 3
53 (29622409) 3
49 (25680717) 1
CT elbow without IV contrast May be appropriate Limited ☢☢ 0.1-1mSv 5 5 3 1 1 1 8 0 0 0 0
References Study Quality
47 (8956595) 4
MR arthrography elbow Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 0 2 0 1 0 0 0 0
MRI elbow without and with IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 3 3 6 0 4 0 3 0 1 0 0
References Study Quality
50 (21845447) 3
54 (8079837) 4
55 (15172385) 4
51 (16481216) 3
47 (8956595) 4
48 (28842238) 2
52 (29602661) 3
53 (29622409) 3
49 (25680717) 1
CT arthrography elbow Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 1 1 12 1 0 0 1 0 0 0 0
CT elbow with IV contrast Usually not appropriate Limited ☢☢ 0.1-1mSv 1 1 11 0 0 0 1 1 1 0 0
References Study Quality
47 (8956595) 4
CT elbow without and with IV contrast Usually not appropriate Limited ☢☢ 0.1-1mSv 1 1 11 0 0 0 2 0 1 0 0
References Study Quality
47 (8956595) 4
3-phase bone scan elbow Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 14 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.