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 hindfoot/ankle May be appropriate Varies Varies 6 n/a 0 0 0 0 0 0 0 0 0
MRI hindfoot/ankle 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 hindfoot/ankle without IV contrast May be appropriate ☢ <0.1 mSv 4 n/a 0 0 0 0 0 0 0 0 0
CT hindfoot/ankle with IV contrast Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT hindfoot/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 hindfoot/ankle Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
MRI hindfoot/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 hindfoot/ankle Usually not appropriate ☢☢☢ 1-10 mSv 1 n/a 0 0 0 0 0 0 0 0 0
US hindfoot/ankle Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
CT arthrography hindfoot/ankle Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
MR arthrography hindfoot/ankle 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 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 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 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 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
Please refer to the supporting documentation for a more complete discussion of the concepts and their definitions below.
Final Tabulations:
A histogram of the number of panel members who rated the recommendation as noted in the column heading (ie, 1, 2, 3, …etc.)
Disagree:
The variation of the individual ratings from the median rating indicates panel disagreement on the final recommendation.
References:
Lists the references associated with the recommendation
SQ:
Study Quality (1, 2, 3, 4, Good M or Inadequate M) of the references listed.
RRL:
Information on the Relative Radiation Level (RRL) designations can be found here.