American College of Radiology
ACR Appropriateness Criteria®

Chronic Ankle Pain

Variant 1: Chronic ankle pain. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography ankle Usually appropriate ☢ <0.1 mSv 9 n/a 0 0 0 0 0 0 0 0 0
CT ankle with IV contrast Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT ankle without IV contrast Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT ankle without and with IV contrast Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
MRI ankle 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
MRI ankle 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
Tc-99m bone scan ankle Usually not appropriate ☢☢☢ 1-10 mSv 1 n/a 0 0 0 0 0 0 0 0 0
US ankle Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Variant 2: Chronic ankle pain. Multiple sites of degenerative joint disease in the hindfoot detected by ankle radiographs. Next study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Image-guided anesthetic injection ankle and hindfoot May be appropriate Varies Varies Varies 6 n/a 0 0 0 0 0 0 0 0 0
MRI ankle and hindfoot 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 ankle and hindfoot without IV contrast May be appropriate ☢ <0.1 mSv 4 n/a 0 0 0 0 0 0 0 0 0
CT ankle and hindfoot with IV contrast Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT ankle and hindfoot without and with IV contrast Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
X-ray arthrography ankle and hindfoot Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
MRI ankle and hindfoot 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
Tc-99m bone scan ankle and hindfoot Usually not appropriate ☢☢☢ 1-10 mSv 1 n/a 0 0 0 0 0 0 0 0 0
US ankle and hindfoot Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
CT arthrography ankle and hindfoot Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
MR arthrography ankle and hindfoot Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Variant 3: Chronic ankle pain. Ankle radiographs normal, suspected osteochondral lesion. Next study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI ankle 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 arthrography ankle May be appropriate ☢ <0.1 mSv 6 n/a 0 0 0 0 0 0 0 0 0
MR arthrography ankle May be appropriate O 0 mSv O 0 mSv [ped] 6 n/a 0 0 0 0 0 0 0 0 0
Tc-99m bone scan with SPECT/CT ankle May be appropriate (Disagreement) ☢☢☢ 1-10 mSv 5 4 4 1 1 4 4 3 0 0 0
CT ankle without IV contrast May be appropriate ☢ <0.1 mSv 4 n/a 0 0 0 0 0 0 0 0 0
Image-guided anesthetic injection ankle Usually not appropriate Varies Varies Varies 3 3 8 0 1 3 4 1 0 0 0
CT ankle with IV contrast Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT ankle without and with IV contrast Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
US ankle Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Radiography ankle stress views Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
MRI ankle 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 arthrography ankle Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
Variant 4: Chronic ankle pain. Ankle radiographs normal or nonspecific, suspected tendon abnormality. Next study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI ankle 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 ankle Usually appropriate O 0 mSv O 0 mSv [ped] 8 n/a 0 0 0 0 0 0 0 0 0
US-guided anesthetic injection ankle tendon sheath May be appropriate O 0 mSv O 0 mSv [ped] 6 n/a 0 0 0 0 0 0 0 0 0
MRI ankle without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 3 n/a 0 0 0 0 0 0 0 0 0
CT arthrography ankle Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT ankle with IV contrast Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT ankle without IV contrast Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT ankle without and with IV contrast Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
Fluoroscopy tenography ankle Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
X-ray arthrography ankle Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
MR arthrography ankle Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Tc-99m bone scan ankle Usually not appropriate ☢☢☢ 1-10 mSv 1 n/a 0 0 0 0 0 0 0 0 0
Radiography ankle stress views Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
Variant 5: Chronic ankle pain. Ankle radiographs normal or nonspecific, suspected ankle instability. Next study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI ankle without IV contrast Usually appropriate O 0 mSv O 0 mSv [ped] 9 n/a 0 0 0 0 0 0 0 0 0
MR arthrography ankle Usually appropriate O 0 mSv O 0 mSv [ped] 7 n/a 0 0 0 0 0 0 0 0 0
US ankle May be appropriate O 0 mSv O 0 mSv [ped] 6 n/a 0 0 0 0 0 0 0 0 0
Radiography ankle stress views May be appropriate ☢ <0.1 mSv 6 6 0 0 0 0 4 6 3 4 0
CT arthrography ankle May be appropriate ☢ <0.1 mSv 5 n/a 0 0 0 0 0 0 0 0 0
CT ankle with IV contrast Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT ankle without IV contrast Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT ankle without and with IV contrast Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
X-ray arthrography ankle Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
Image-guided anesthetic injection ankle Usually not appropriate Varies Varies Varies 1 n/a 0 0 0 0 0 0 0 0 0
MRI ankle 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
Tc-99m bone scan ankle Usually not appropriate ☢☢☢ 1-10 mSv 1 n/a 0 0 0 0 0 0 0 0 0
Variant 6: Chronic ankle pain. Ankle radiographs normal or nonspecific, suspected ankle impingement syndrome. Next study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI ankle without IV contrast Usually appropriate O 0 mSv O 0 mSv [ped] 9 9 0 0 1 0 2 2 2 1 8
MR arthrography ankle May be appropriate O 0 mSv O 0 mSv [ped] 6 n/a 0 0 0 0 0 0 0 0 0
CT arthrography ankle May be appropriate ☢ <0.1 mSv 5 n/a 0 0 0 0 0 0 0 0 0
US ankle May be appropriate O 0 mSv O 0 mSv [ped] 5 n/a 0 0 0 0 0 0 0 0 0
CT ankle without IV contrast May be appropriate ☢ <0.1 mSv 5 5 0 0 0 2 10 2 2 1 0
Image-guided anesthetic injection ankle May be appropriate (Disagreement) Varies Varies Varies 5 4 0 3 3 4 4 1 0 2 0
Tc-99m 3-phase bone scan with SPECT/CT ankle Usually not appropriate ☢☢☢ 1-10 mSv 2 2 8 2 0 3 3 0 0 0 0
MRI ankle without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 2 2 8 3 4 2 0 0 0 0 0
CT ankle with IV contrast Usually not appropriate ☢ <0.1 mSv 1 1 14 2 0 0 0 0 0 0 0
CT ankle without and with IV contrast Usually not appropriate ☢ <0.1 mSv 1 1 14 0 2 0 0 0 0 0 0
Radiography ankle stress views Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
X-ray arthrography ankle Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
Variant 7: Chronic ankle pain. Ankle radiographs normal, pain of uncertain etiology. Next study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI ankle 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 ankle without IV contrast May be appropriate ☢ <0.1 mSv 5 5 0 0 0 0 11 4 2 0 0
Tc-99m bone scan with SPECT/CT ankle May be appropriate (Disagreement) ☢☢☢ 1-10 mSv 5 4 2 3 3 2 4 3 0 0 0
Image-guided anesthetic injection ankle May be appropriate Varies Varies Varies 4 4 5 1 1 2 5 1 1 0 0
US ankle May be appropriate O 0 mSv O 0 mSv [ped] 4 4 5 2 0 6 3 0 0 0 1
CT arthrography ankle Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT ankle with IV contrast Usually not appropriate ☢ <0.1 mSv 1 1 16 0 0 0 0 0 0 0 0
CT ankle without and with IV contrast Usually not appropriate ☢ <0.1 mSv 1 1 16 0 0 0 0 0 0 0 0
X-ray arthrography ankle Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
MR arthrography ankle Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
MRI ankle 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
Radiography ankle stress views Usually not appropriate ☢ <0.1 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.