American College of Radiology
ACR Appropriateness Criteria®

Suspected Osteomyelitis of the Foot in Patients with Diabetes Mellitus

Variant 1: Suspected osteomyelitis of the foot in patients with diabetes mellitus. 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 Limited ☢ <0.1 mSv ☢ <0.03 mSv [ped] 9 9 0 0 0 0 0 0 0 0 11
References Study Quality
11 (28366223) 4
12 (21636263) 4
13 (20567730) 4
CT foot with IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 10 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 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 10 0 1 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 10 0 0 1 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 9 0 0 1 1 0 0 0 0
Tc-99m 3-phase bone scan foot Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 10 0 0 0 0 1 0 0 0
FDG-PET/CT foot Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 11 0 0 0 0 0 0 0 0
US foot Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 0 0 0 0 0 0 0 0
In-111 WBC and Tc-99m sulfur colloid marrow scan foot Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 10 0 0 0 0 1 0 0 0
In-111 WBC scan foot Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 10 0 0 0 0 1 0 0 0
Tc-99m 3-phase bone scan and In-111 WBC scan and Tc-99m sulfur colloid marrow scan foot Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 9 0 0 0 1 1 0 0 0
Tc-99m 3-phase bone scan and In-111 WBC scan foot Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 10 0 0 0 0 1 0 0 0
Tc-99m 3-phase bone scan and In-111 WBC scan with SPECT/CT foot Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 10 0 0 0 0 1 0 0 0
Variant 2: Soft-tissue swelling without ulcer. Suspected osteomyelitis or early neuropathic arthropathy changes of the foot in patients with diabetes mellitus. Additional imaging following radiographs.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI foot without and with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 1 0 0 0 0 0 1 1 8
References Study Quality
2 (28497161) 3
17 (24764120) 4
21 (16037509) 3
20 (9169715) 3
19 (18956147) 3
18 (15863990) 3
29 (15049523) 4
28 (8518119) 3
27 (21868781) 4
26 (23897135) 3
25 (10421237) 3
24 (18036160) 2
23 (17242312) M
22 (19098186) 3
MRI foot without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 1 0 0 1 1 1 4 3
References Study Quality
2 (28497161) 3
22 (19098186) 3
21 (16037509) 3
20 (9169715) 3
19 (18956147) 3
18 (15863990) 3
17 (24764120) 4
28 (8518119) 3
27 (21868781) 4
26 (23897135) 3
25 (10421237) 3
24 (18036160) 2
23 (17242312) M
29 (15049523) 4
CT foot with IV contrast May be appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 5 5 0 0 0 1 9 2 0 0 0
References Study Quality
15 (29058098) 4
16 (18025514) 4
17 (24764120) 4
13 (20567730) 4
3 (27587513) 4
CT foot without IV contrast May be appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 5 5 1 0 2 1 5 2 0 0 0
References Study Quality
3 (27587513) 4
13 (20567730) 4
15 (29058098) 4
16 (18025514) 4
17 (24764120) 4
Tc-99m 3-phase bone scan and In-111 WBC scan with SPECT/CT foot May be appropriate Strong ☢☢☢☢ 10-30 mSv 5 5 0 1 0 0 10 1 0 0 0
References Study Quality
47 (17138732) 2
48 (14523585) 3
49 (17146681) 3
50 (27560470) 3
51 (20851003) 2
FDG-PET/CT foot May be appropriate Strong ☢☢☢☢ 10-30 mSv 4 4 4 1 1 3 3 0 0 0 0
References Study Quality
39 (17460537) 2
44 (12766596) 3
43 (15750157) 3
42 (22801731) 1
41 (23905618) 4
40 (15680102) 2
46 (21934545) M
45 (14990668) 4
In-111 WBC scan foot May be appropriate Limited ☢☢☢☢ 10-30 mSv 4 4 1 1 2 2 5 0 0 0 0
References Study Quality
34 (16702459) 4
35 (3157204) 3
Tc-99m 3-phase bone scan and In-111 WBC scan foot May be appropriate Limited ☢☢☢☢ 10-30 mSv 4 4 1 1 0 5 5 0 0 0 0
References Study Quality
32 (3171695) 3
33 (2341891) 3
In-111 WBC and Tc-99m sulfur colloid marrow scan foot Usually not appropriate Limited ☢☢☢☢ 10-30 mSv 2 2 6 2 1 1 2 0 0 0 0
References Study Quality
36 (9476948) 3
37 (17127204) 4
Tc-99m 3-phase bone scan and In-111 WBC scan and Tc-99m sulfur colloid marrow scan foot Usually not appropriate Limited ☢☢☢☢ 10-30 mSv 2 2 4 3 0 2 2 0 1 0 0
References Study Quality
36 (9476948) 3
38 (26706230) 3
CT foot without and with IV contrast Usually not appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 11 0 1 0 0 0 0 0 0
References Study Quality
3 (27587513) 4
13 (20567730) 4
15 (29058098) 4
16 (18025514) 4
17 (24764120) 4
Tc-99m 3-phase bone scan foot Usually not appropriate Limited ☢☢☢ 1-10 mSv 1 1 6 0 1 2 1 1 0 0 0
References Study Quality
30 (26883537) 4
31 (10395336) 3
US foot Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 7 1 0 2 1 0 0 0 0
Variant 3: Soft-tissue swelling with ulcer. Suspected osteomyelitis of the foot in patients with diabetes mellitus with or without neuropathic arthropathy. Additional imaging following radiographs.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI foot without and with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 1 0 0 0 0 0 1 2 7
References Study Quality
2 (28497161) 3
21 (16037509) 3
20 (9169715) 3
19 (18956147) 3
18 (15863990) 3
17 (24764120) 4
29 (15049523) 4
28 (8518119) 3
27 (21868781) 4
26 (23897135) 3
25 (10421237) 3
24 (18036160) 2
23 (17242312) M
22 (19098186) 3
MRI foot without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 1 0 0 1 0 2 4 3
References Study Quality
2 (28497161) 3
22 (19098186) 3
21 (16037509) 3
20 (9169715) 3
19 (18956147) 3
18 (15863990) 3
17 (24764120) 4
27 (21868781) 4
26 (23897135) 3
25 (10421237) 3
24 (18036160) 2
23 (17242312) M
28 (8518119) 3
29 (15049523) 4
CT foot with IV contrast May be appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 5 5 0 0 0 2 8 1 1 0 0
References Study Quality
3 (27587513) 4
13 (20567730) 4
15 (29058098) 4
16 (18025514) 4
17 (24764120) 4
CT foot without IV contrast May be appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 5 5 1 0 1 2 4 2 1 0 0
References Study Quality
3 (27587513) 4
13 (20567730) 4
15 (29058098) 4
16 (18025514) 4
17 (24764120) 4
Tc-99m 3-phase bone scan foot May be appropriate (Disagreement) Expert Opinion ☢☢☢ 1-10 mSv 5 5 1 0 4 1 0 1 2 3 0
References Study Quality
30 (26883537) 4
31 (10395336) 3
Tc-99m 3-phase bone scan and In-111 WBC scan foot May be appropriate Limited ☢☢☢☢ 10-30 mSv 5 5 1 1 0 4 5 1 0 0 0
References Study Quality
30 (26883537) 4
31 (10395336) 3
Tc-99m 3-phase bone scan and In-111 WBC scan with SPECT/CT foot May be appropriate Strong ☢☢☢☢ 10-30 mSv 5 5 0 0 0 0 10 2 0 0 0
References Study Quality
51 (20851003) 2
50 (27560470) 3
49 (17146681) 3
48 (14523585) 3
47 (17138732) 2
FDG-PET/CT foot May be appropriate Strong ☢☢☢☢ 10-30 mSv 4 4 3 0 2 3 4 0 0 0 0
References Study Quality
39 (17460537) 2
46 (21934545) M
45 (14990668) 4
44 (12766596) 3
43 (15750157) 3
42 (22801731) 1
41 (23905618) 4
40 (15680102) 2
In-111 WBC scan foot May be appropriate Limited ☢☢☢☢ 10-30 mSv 4 4 1 1 1 3 5 0 0 0 0
References Study Quality
35 (3157204) 3
34 (16702459) 4
In-111 WBC and Tc-99m sulfur colloid marrow scan foot Usually not appropriate Limited ☢☢☢☢ 10-30 mSv 2 2 6 2 1 1 2 0 0 0 0
References Study Quality
36 (9476948) 3
37 (17127204) 4
Tc-99m 3-phase bone scan and In-111 WBC scan and Tc-99m sulfur colloid marrow scan foot Usually not appropriate Limited ☢☢☢☢ 10-30 mSv 2 2 6 2 0 1 2 0 1 0 0
References Study Quality
36 (9476948) 3
38 (26706230) 3
CT foot without and with IV contrast Usually not appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 10 0 1 0 0 0 0 0 0
References Study Quality
3 (27587513) 4
13 (20567730) 4
15 (29058098) 4
16 (18025514) 4
17 (24764120) 4
US foot Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 7 1 2 1 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.