American College of Radiology
ACR Appropriateness Criteria®

Acute Trauma to the Foot

Variant 1: Adult or child >5 years old. Acute injury to the foot; positive Ottawa Rules, suspicious for fracture. First study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
X-ray foot Usually appropriate ☢ <0.1 mSv ☢ <0.03 mSv [ped] 9 n/a 0 0 0 0 0 0 0 0 0
CT foot with IV contrast Usually not appropriate ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
MRI foot without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
CT foot without and with IV contrast Usually not appropriate ☢ <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 ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
MRI foot without IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
US foot Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Variant 2: Adult or child >5 years old. Acute injury to the foot; does not meet the Ottawa Rules; no focal tenderness in the foot or palpable abnormality of the foot on physical examination; able to walk; neurologically intact (including no peripheral neuropathy). First study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
CT foot without and with IV contrast Usually not appropriate ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
CT foot with IV contrast Usually not appropriate ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
MRI foot without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
X-ray foot Usually not appropriate ☢ <0.1 mSv ☢ <0.03 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
US foot Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
MRI foot without IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
CT foot without IV contrast Usually not appropriate ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Variant 3: Adult or child >5 years old. Acute injury to the foot; does not meet the Ottawa Rules; patient is not neurologically intact and/or has a peripheral neuropathy that involves the feet. First study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
X-ray foot Usually appropriate ☢ <0.1 mSv ☢ <0.03 mSv [ped] 9 n/a 0 0 0 0 0 0 0 0 0
CT foot without and with IV contrast Usually not appropriate ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
CT foot with IV contrast Usually not appropriate ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
MRI foot without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
US foot Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
MRI foot without IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
CT foot without IV contrast Usually not appropriate ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Variant 4: Adult or child >5 years old. Acute injury to the foot; does not meet the Ottawa Rules; patient has polytrauma. First study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
X-ray foot Usually appropriate ☢ <0.1 mSv ☢ <0.03 mSv [ped] 9 n/a 0 0 0 0 0 0 0 0 0
CT foot without and with IV contrast Usually not appropriate ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
CT foot with IV contrast Usually not appropriate ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
US foot Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
MRI foot without IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
CT foot without IV contrast Usually not appropriate ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
MRI foot without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Variant 5: Adult or child >5 years old. Acute injury to the foot; does not meet the Ottawa Rules; physical examination is concerning for a Lisfranc injury. First study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
X-ray foot Usually appropriate ☢ <0.1 mSv ☢ <0.03 mSv [ped] 9 n/a 0 0 0 0 0 0 0 0 0
X-ray foot with weight bearing Usually appropriate ☢ <0.1 mSv ☢ <0.03 mSv [ped] 7 n/a 0 0 0 0 0 0 0 0 0
CT foot with IV contrast Usually not appropriate ☢ <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 ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
MRI foot without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
US foot Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
MRI foot without IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
CT foot without IV contrast Usually not appropriate ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Variant 6: Adult or child >5 years old. Acute injury to the foot; physical examination is concerning for a Lisfranc injury. Radiographs are normal and patient is not able to tolerate a weight-bearing radiographic view. 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 O 0 mSv O 0 mSv [ped] 9 n/a 0 0 0 0 0 0 0 0 0
CT foot without IV contrast Usually appropriate ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 9 n/a 0 0 0 0 0 0 0 0 0
CT foot with IV contrast Usually not appropriate ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
MRI foot without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
CT foot without and with IV contrast Usually not appropriate ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
US foot Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Variant 7: Adult or child >5 years old. Acute injury to the foot; physical examination is concerning for an acute tendinous rupture or dislocation in the foot; radiographs are negative. 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 O 0 mSv O 0 mSv [ped] 9 n/a 0 0 0 0 0 0 0 0 0
US foot May be appropriate O 0 mSv O 0 mSv [ped] 5 n/a 0 0 0 0 0 0 0 0 0
CT foot without IV contrast May be appropriate ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 5 n/a 0 0 0 0 0 0 0 0 0
CT foot with IV contrast Usually not appropriate ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
MRI foot without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
CT foot without and with IV contrast Usually not appropriate ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Variant 8: Adult or child >5 years old. Metatarsal-phalangeal joint injury. Suspect plantar plate injury. First study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
X-ray foot Usually appropriate ☢ <0.1 mSv ☢ <0.03 mSv [ped] 9 n/a 0 0 0 0 0 0 0 0 0
X-ray foot forced dorsiflexion lateral May be appropriate ☢ <0.1 mSv ☢ <0.03 mSv [ped] 5 n/a 0 0 0 0 0 0 0 0 0
Fluoroscopy foot May be appropriate ☢ <0.1 mSv ☢ <0.03 mSv [ped] 5 n/a 0 0 0 0 0 0 0 0 0
MRI foot without IV contrast May be appropriate O 0 mSv O 0 mSv [ped] 5 n/a 0 0 0 0 0 0 0 0 0
CT foot with IV contrast Usually not appropriate ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
MRI foot without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
CT foot without and with IV contrast Usually not appropriate ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
US foot Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
CT foot without IV contrast Usually not appropriate ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Variant 9: Adult or child >5 years old. Acute injury to the foot; physical examination is concerning for penetrating trauma with a foreign body in the soft tissues. First study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
X-ray foot Usually appropriate ☢ <0.1 mSv ☢ <0.03 mSv [ped] 9 n/a 0 0 0 0 0 0 0 0 0
US foot Usually appropriate O 0 mSv O 0 mSv [ped] 7 n/a 0 0 0 0 0 0 0 0 0
MRI foot without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
CT foot with IV contrast Usually not appropriate ☢ <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 ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
MRI foot without IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
CT foot without IV contrast Usually not appropriate ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Variant 10: Adult or child >5 years old. Acute injury to the foot; physical examination is concerning for penetrating trauma with a foreign body in the soft tissues. Radiographs of the foot are negative. Next best 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 O 0 mSv O 0 mSv [ped] 9 n/a 0 0 0 0 0 0 0 0 0
MRI foot without IV contrast May be appropriate O 0 mSv O 0 mSv [ped] 5 n/a 0 0 0 0 0 0 0 0 0
CT foot without IV contrast May be appropriate ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 5 n/a 0 0 0 0 0 0 0 0 0
MRI foot without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
CT foot with IV contrast Usually not appropriate ☢ <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 ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 n/a 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.