American College of Radiology
ACR Appropriateness Criteria®

Chronic Extremity Joint Pain–Suspected Inflammatory Arthritis

Variant 1: Chronic extremity joint pain. Suspect rheumatoid arthritis.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography appendicular skeleton area of interest Usually appropriate ☢ <0.1 mSv 9 n/a 0 0 0 0 0 0 0 0 0
US appendicular skeleton area of interest Usually appropriate O 0 mSv O 0 mSv [ped] 7 n/a 0 0 0 0 0 0 0 0 0
MRI appendicular skeleton area of interest without IV contrast Usually appropriate O 0 mSv O 0 mSv [ped] 7 n/a 0 0 0 0 0 0 0 0 0
MRI appendicular skeleton area of interest without and with IV contrast Usually appropriate O 0 mSv O 0 mSv [ped] 7 n/a 0 0 0 0 0 0 0 0 0
CT appendicular skeleton area of interest without IV contrast May be appropriate Varies Varies 4 n/a 0 0 0 0 0 0 0 0 0
CT appendicular skeleton area of interest with IV contrast Usually not appropriate Varies Varies 3 n/a 0 0 0 0 0 0 0 0 0
FDG-PET/CT whole body Usually not appropriate ☢☢☢☢ 10-30 mSv 2 n/a 0 0 0 0 0 0 0 0 0
Tc-99m bone scan whole body Usually not appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 n/a 0 0 0 0 0 0 0 0 0
CT appendicular skeleton area of interest without and with IV contrast Usually not appropriate Varies Varies 1 n/a 0 0 0 0 0 0 0 0 0
Variant 2: Chronic extremity joint pain. Suspect seronegative spondyloarthropathy.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography appendicular skeleton area of interest Usually appropriate ☢ <0.1 mSv 9 n/a 0 0 0 0 0 0 0 0 0
US appendicular skeleton area of interest Usually appropriate O 0 mSv O 0 mSv [ped] 7 n/a 0 0 0 0 0 0 0 0 0
MRI appendicular skeleton area of interest without and with IV contrast Usually appropriate O 0 mSv O 0 mSv [ped] 7 n/a 0 0 0 0 0 0 0 0 0
MRI appendicular skeleton area of interest without IV contrast May be appropriate O 0 mSv O 0 mSv [ped] 6 n/a 0 0 0 0 0 0 0 0 0
CT appendicular skeleton area of interest without IV contrast May be appropriate Varies Varies 4 n/a 0 0 0 0 0 0 0 0 0
CT appendicular skeleton area of interest with IV contrast Usually not appropriate Varies Varies 3 n/a 0 0 0 0 0 0 0 0 0
FDG-PET/CT whole body Usually not appropriate ☢☢☢☢ 10-30 mSv 2 n/a 0 0 0 0 0 0 0 0 0
CT appendicular skeleton area of interest without and with IV contrast Usually not appropriate Varies Varies 1 n/a 0 0 0 0 0 0 0 0 0
Tc-99m bone scan whole body Usually not appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Variant 3: Chronic extremity joint pain. Suspect gout.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography appendicular skeleton area of interest Usually appropriate ☢ <0.1 mSv 9 n/a 0 0 0 0 0 0 0 0 0
US appendicular skeleton area of interest Usually appropriate O 0 mSv O 0 mSv [ped] 7 n/a 0 0 0 0 0 0 0 0 0
CT appendicular skeleton area of interest without IV contrast Usually appropriate Varies Varies 7 n/a 0 0 0 0 0 0 0 0 0
MRI appendicular skeleton area of interest without IV contrast May be appropriate O 0 mSv O 0 mSv [ped] 6 n/a 0 0 0 0 0 0 0 0 0
MRI appendicular skeleton area of interest without and with 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 appendicular skeleton area of interest without and with IV contrast Usually not appropriate Varies Varies 1 n/a 0 0 0 0 0 0 0 0 0
CT appendicular skeleton area of interest with IV contrast Usually not appropriate Varies Varies 1 n/a 0 0 0 0 0 0 0 0 0
FDG-PET/CT whole body Usually not appropriate ☢☢☢☢ 10-30 mSv 1 n/a 0 0 0 0 0 0 0 0 0
Tc-99m bone scan whole body Usually not appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Variant 4: Chronic extremity joint pain. Suspect calcium pyrophosphate dihydrate disease (pseudogout).
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography area of interest Usually appropriate Varies Varies 9 n/a 0 0 0 0 0 0 0 0 0
US area of interest May be appropriate O 0 mSv O 0 mSv [ped] 5 n/a 0 0 0 0 0 0 0 0 0
CT area of interest without IV contrast May be appropriate Varies Varies 5 n/a 0 0 0 0 0 0 0 0 0
MRI area of interest 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
MRI area of interest without and with 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 area of interest without and with IV contrast Usually not appropriate Varies Varies 1 n/a 0 0 0 0 0 0 0 0 0
CT area of interest with IV contrast Usually not appropriate Varies Varies 1 n/a 0 0 0 0 0 0 0 0 0
Tc-99m bone scan whole body Usually not appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
FDG-PET/CT whole body Usually not appropriate ☢☢☢☢ 10-30 mSv 1 n/a 0 0 0 0 0 0 0 0 0
Variant 5: Chronic extremity joint pain. Suspect erosive osteoarthritis.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography area of interest Usually appropriate Varies Varies 9 n/a 0 0 0 0 0 0 0 0 0
US area of interest May be appropriate O 0 mSv O 0 mSv [ped] 5 n/a 0 0 0 0 0 0 0 0 0
MRI area of interest 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
MRI area of interest without and with 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 area of interest without IV contrast May be appropriate Varies Varies 4 n/a 0 0 0 0 0 0 0 0 0
CT area of interest without and with IV contrast Usually not appropriate Varies Varies 1 n/a 0 0 0 0 0 0 0 0 0
CT area of interest with IV contrast Usually not appropriate Varies Varies 1 n/a 0 0 0 0 0 0 0 0 0
Tc-99m bone scan whole body Usually not appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
FDG-PET/CT whole body Usually not appropriate ☢☢☢☢ 10-30 mSv 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.