American College of Radiology
ACR Appropriateness Criteria®

Suspected Osteomyelitis of the Foot in Patients with Diabetes Mellitus

Variant 1: Soft-tissue swelling without neuropathic arthropathy or ulcer.
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 O 0 mSv O 0 mSv [ped] 9 n/a 0 0 0 0 0 0 0 0 0
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
X-ray foot Usually appropriate ☢ <0.1 mSv ☢ <0.03 mSv [ped] 9 n/a 0 0 0 0 0 0 0 0 0
Labeled leukocyte scan foot (In-111 or Tc-99m) Usually not appropriate ☢☢☢☢ 10-30 mSv 3 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
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
FDG-PET/CT foot Usually not appropriate ☢☢☢☢ 10-30 mSv 1 n/a 0 0 0 0 0 0 0 0 0
Labeled leukocyte scan (In-111 or Tc-99m) and Tc-99m sulfur colloid marrow scan foot Usually not appropriate ☢☢☢☢ 10-30 mSv 1 n/a 0 0 0 0 0 0 0 0 0
Tc-99m 3-phase bone scan and labeled leukocyte scan (In-111 or Tc-99m) and Tc-99m sulfur colloid marrow scan foot Usually not appropriate ☢☢☢☢ 10-30 mSv 1 n/a 0 0 0 0 0 0 0 0 0
Tc-99m 3-phase bone scan and labeled leukocyte scan (In-111 or Tc-99m) foot Usually not appropriate ☢☢☢☢ 10-30 mSv 1 n/a 0 0 0 0 0 0 0 0 0
Tc-99m 3-phase bone scan foot Usually not appropriate ☢☢☢ 1-10 mSv 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: Soft-tissue swelling with neuropathic arthropathy without ulcer.
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
MRI foot without and with IV contrast 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 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 May be appropriate ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 5 n/a 0 0 0 0 0 0 0 0 0
Labeled leukocyte scan foot (In-111 or Tc-99m) Usually not appropriate ☢☢☢☢ 10-30 mSv 3 n/a 0 0 0 0 0 0 0 0 0
Labeled leukocyte scan (In-111 or Tc-99m) and Tc-99m sulfur colloid marrow scan foot Usually not appropriate ☢☢☢☢ 10-30 mSv 3 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
Tc-99m 3-phase bone scan foot Usually not appropriate ☢☢☢ 1-10 mSv 1 n/a 0 0 0 0 0 0 0 0 0
Tc-99m 3-phase bone scan and labeled leukocyte scan (In-111 or Tc-99m) foot Usually not appropriate ☢☢☢☢ 10-30 mSv 1 n/a 0 0 0 0 0 0 0 0 0
Tc-99m 3-phase bone scan and labeled leukocyte scan (In-111 or Tc-99m) and Tc-99m sulfur colloid marrow scan foot Usually not appropriate ☢☢☢☢ 10-30 mSv 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
FDG-PET/CT foot Usually not appropriate ☢☢☢☢ 10-30 mSv 1 n/a 0 0 0 0 0 0 0 0 0
Variant 3: Soft-tissue swelling without neuropathic arthropathy with ulcer.
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
MRI foot without and with IV contrast 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 Usually appropriate O 0 mSv O 0 mSv [ped] 9 n/a 0 0 0 0 0 0 0 0 0
Labeled leukocyte scan foot (In-111 or Tc-99m) Usually not appropriate ☢☢☢☢ 10-30 mSv 3 n/a 0 0 0 0 0 0 0 0 0
Tc-99m 3-phase bone scan and labeled leukocyte scan (In-111 or Tc-99m) foot Usually not appropriate ☢☢☢☢ 10-30 mSv 1 n/a 0 0 0 0 0 0 0 0 0
Tc-99m 3-phase bone scan foot Usually not appropriate ☢☢☢ 1-10 mSv 1 n/a 0 0 0 0 0 0 0 0 0
Labeled leukocyte scan (In-111 or Tc-99m) and Tc-99m sulfur colloid marrow scan foot Usually not appropriate ☢☢☢☢ 10-30 mSv 1 n/a 0 0 0 0 0 0 0 0 0
Tc-99m 3-phase bone scan and labeled leukocyte scan (In-111 or Tc-99m) and Tc-99m sulfur colloid marrow scan foot Usually not appropriate ☢☢☢☢ 10-30 mSv 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
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
FDG-PET/CT foot Usually not appropriate ☢☢☢☢ 10-30 mSv 1 n/a 0 0 0 0 0 0 0 0 0
Variant 4: Soft-tissue swelling with neuropathic arthropathy and ulcer.
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
MRI foot without and with IV contrast 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 Usually appropriate O 0 mSv O 0 mSv [ped] 9 n/a 0 0 0 0 0 0 0 0 0
Labeled leukocyte scan (In-111 or Tc-99m) and Tc-99m sulfur colloid marrow scan foot Usually not appropriate ☢☢☢☢ 10-30 mSv 3 n/a 0 0 0 0 0 0 0 0 0
Labeled leukocyte scan foot (In-111 or Tc-99m) Usually not appropriate ☢☢☢☢ 10-30 mSv 1 n/a 0 0 0 0 0 0 0 0 0
Tc-99m 3-phase bone scan and labeled leukocyte scan (In-111 or Tc-99m) foot Usually not appropriate ☢☢☢☢ 10-30 mSv 1 n/a 0 0 0 0 0 0 0 0 0
Tc-99m 3-phase bone scan foot Usually not appropriate ☢☢☢ 1-10 mSv 1 n/a 0 0 0 0 0 0 0 0 0
Tc-99m 3-phase bone scan and labeled leukocyte scan (In-111 or Tc-99m) and Tc-99m sulfur colloid marrow scan foot Usually not appropriate ☢☢☢☢ 10-30 mSv 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
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
FDG-PET/CT foot 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.