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Appropriateness Criteria

Variant 1: Chronic foot pain. Unknown etiology. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography foot Usually appropriate Moderate ☢ <0.1 mSv ☢ <0.03 mSv [ped] 9 9 0 0 0 0 0 0 0 0 0
References Study Quality
11 (18894612) 4
13 (25805712) 4
14 (23811947) 4
15 (16697701) 2
5 (20439021) 4
12 (8356270) 4
US foot Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 0 0 0 0 0 0 0 0 0
MRI foot 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 foot 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 foot 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 foot 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 foot 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 foot 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: Persistent posttraumatic foot pain. Radiographs negative or equivocal. Clinical concern includes complex regional pain syndrome type I. 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 foot without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
20 (7892471) 3
19 (17515744) 2
17 (22177715) Inadequate
18 (24161450) 4
3-phase bone scan foot Usually appropriate Limited ☢☢☢ 1-10 mSv 7 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
16 (1620860) 3
17 (22177715) Inadequate
MRI foot without and with IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
20 (7892471) 3
19 (17515744) 2
17 (22177715) Inadequate
18 (24161450) 4
US foot Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
22 (9798855) 4
CT foot with IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
CT foot without and with IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
CT foot without IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Variant 3: Chronic metatarsalgia including plantar great toe pain. Radiographs negative or equivocal. Clinical concern includes sesamoiditis, Morton’s neuroma, intermetatarsal bursitis, chronic plantar plate injury, or Freiberg’s infraction. 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 foot without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 0 3 10
References Study Quality
39 (8372200) 4
37 (9114115) 3
38 (17420632) 3
36 (25809742) Good
40 (22727342) 2
32 (11706214) 4
44 (19038613) 4
41 (28109309) 4
12 (8356270) 4
33 (9765133) 4
34 (10551246) 3
35 (9016241) 3
42 (20308514) 4
43 (12668744) 4
45 (30685010) 4
US foot May be appropriate Strong O 0 mSv O 0 mSv [ped] 6 6 0 0 0 0 5 3 3 2 0
References Study Quality
49 (16819605) 3
36 (25809742) Good
47 (25466436) 4
41 (28109309) 4
46 (25027985) 2
48 (28398696) 2
MRI foot without and with IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 5 5 0 0 2 1 9 1 0 0 1
References Study Quality
37 (9114115) 3
38 (17420632) 3
36 (25809742) Good
40 (22727342) 2
32 (11706214) 4
44 (19038613) 4
41 (28109309) 4
12 (8356270) 4
33 (9765133) 4
34 (10551246) 3
35 (9016241) 3
42 (20308514) 4
43 (12668744) 4
45 (30685010) 4
CT foot without IV contrast May be appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 5 5 1 0 0 1 7 2 2 0 0
References Study Quality
29 (19038614) 4
30 (21817003) 3
28 (12627621) 4
31 (8079860) 4
Bone scan foot May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 1 0 3 2 6 2 0 0 0
References Study Quality
12 (8356270) 4
24 (7633586) 2
26 (11595853) 4
27 (3806228) 4
CT foot with IV contrast Usually not appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 11 0 2 0 0 0 0 0 0
References Study Quality
29 (19038614) 4
30 (21817003) 3
28 (12627621) 4
31 (8079860) 4
CT foot without and with IV contrast Usually not appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 12 0 1 0 0 0 0 0 0
References Study Quality
29 (19038614) 4
30 (21817003) 3
28 (12627621) 4
31 (8079860) 4
Variant 4: Chronic plantar heel pain. Radiographs negative or equivocal. Clinical concern includes plantar fasciitis or plantar fascia tear. 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 foot Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 1 2 4 4 2
References Study Quality
58 (19664484) 4
54 (16040817) 1
57 (27957702) 4
55 (-3145751) 3
56 (-3145753) 2
MRI foot without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 0 2 11
References Study Quality
52 (10470906) 4
53 (20964964) 3
MRI foot without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 8 0 2 1 1 1 0 0 0
References Study Quality
52 (10470906) 4
53 (20964964) 3
CT foot with IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 12 1 0 0 0 0 0 0 0
CT foot without and with IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 13 0 0 0 0 0 0 0 0
CT foot without IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 10 0 0 2 1 0 0 0 0
Bone scan with SPECT or SPECT/CT foot Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 5 1 2 3 1 0 1 0 0
References Study Quality
50 (18806575) 4
51 (2054987) 4
Variant 5: Nonradiating chronic midfoot pain of suspected osseous origin. Radiographs negative or equivocal. Clinical concern includes occult fracture, or painful accessory ossicles. 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 foot without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 0 2 11
References Study Quality
72 (22078792) 4
69 (8571860) 4
65 (11858605) 4
74 (27888854) 4
71 (26888876) 2
75 (27885856) 4
64 (29876712) 3
70 (26557590) 3
73 (29228800) 4
CT foot without IV contrast Usually appropriate Moderate ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 7 7 0 0 0 0 4 0 3 4 2
References Study Quality
69 (8571860) 4
66 (15333345) 3
65 (11858605) 4
68 (15018183) 4
67 (29679212) Good
64 (29876712) 3
Bone scan foot May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 0 0 3 6 3 1 1 0 0
References Study Quality
61 (1424449) 4
60 (21540716) 4
62 (15230772) 4
63 (25210293) 4
59 (30788224) 4
US foot Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 5 0 4 1 2 1 0 0 0
References Study Quality
78 (20489099) 2
79 (18064426) 3
62 (15230772) 4
77 (22506252) 4
76 (10477883) 4
MRI foot without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 9 0 2 0 1 1 0 0 0
References Study Quality
72 (22078792) 4
69 (8571860) 4
65 (11858605) 4
74 (27888854) 4
71 (26888876) 2
75 (27885856) 4
63 (25210293) 4
64 (29876712) 3
70 (26557590) 3
73 (29228800) 4
CT foot with IV contrast Usually not appropriate Moderate ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 12 0 1 0 0 0 0 0 0
References Study Quality
69 (8571860) 4
66 (15333345) 3
65 (11858605) 4
68 (15018183) 4
67 (29679212) Good
64 (29876712) 3
CT foot without and with IV contrast Usually not appropriate Moderate ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 13 0 0 0 0 0 0 0 0
References Study Quality
69 (8571860) 4
66 (15333345) 3
65 (11858605) 4
68 (15018183) 4
67 (29679212) Good
64 (29876712) 3
Variant 6: Chronic foot pain. Entrapment Syndromes. Radiographs negative or equivocal. Clinical concern includes Baxter’s neuropathy. 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 foot Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 1 0 2 0 0 11 0 0
References Study Quality
81 (23980227) 3
MRI foot without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 1 1 11
References Study Quality
80 (19703848) 2
MRI foot without and with IV contrast Usually not appropriate Expert Opinion O 0 mSv O 0 mSv [ped] 1 1 10 0 0 0 1 1 0 0 1
References Study Quality
80 (19703848) 2
CT foot with IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 12 0 1 0 0 0 0 0 0
CT foot without and with IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 12 0 1 0 0 0 0 0 0
CT foot without IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 10 0 2 0 0 1 0 0 0
Bone scan with SPECT or SPECT/CT foot Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 13 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.