American College of Radiology
ACR Appropriateness Criteria®

Chronic Elbow Pain

Variant 1: Evaluation for chronic elbow pain. First test.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography elbow Usually appropriate ☢ <0.1 mSv 9 n/a 0 0 0 0 0 0 0 0 0
CT arthrography elbow Usually not appropriate ☢☢ 0.1-1mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT elbow without IV contrast Usually not appropriate ☢☢ 0.1-1mSv 1 n/a 0 0 0 0 0 0 0 0 0
MR arthrography elbow Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
MRI elbow 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
US elbow Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
MRI elbow 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
CT elbow without and with IV contrast Usually not appropriate ☢☢ 0.1-1mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT elbow with IV contrast Usually not appropriate ☢☢ 0.1-1mSv 1 n/a 0 0 0 0 0 0 0 0 0
Tc-99m MDP 3-phase bone scan elbow Usually not appropriate ☢☢☢ 1-10 mSv 1 n/a 0 0 0 0 0 0 0 0 0
Variant 2: Mechanical symptoms (locking, clicking, limited motion); suspect intra-articular osteocartilaginous body or synovial abnormality; radiographs nondiagnostic.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MR arthrography elbow Usually appropriate O 0 mSv O 0 mSv [ped] 9 n/a 0 0 0 0 0 0 0 0 0
MRI elbow 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 elbow Usually appropriate ☢☢ 0.1-1mSv 8 n/a 0 0 0 0 0 0 0 0 0
CT elbow without IV contrast Usually appropriate ☢☢ 0.1-1mSv 8 n/a 0 0 0 0 0 0 0 0 0
US elbow Usually not appropriate O 0 mSv O 0 mSv [ped] 3 n/a 0 0 0 0 0 0 0 0 0
Tc-99m MDP 3-phase bone scan elbow Usually not appropriate ☢☢☢ 1-10 mSv 1 n/a 0 0 0 0 0 0 0 0 0
MRI elbow 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
CT elbow without and with IV contrast Usually not appropriate ☢☢ 0.1-1mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT elbow with IV contrast Usually not appropriate ☢☢ 0.1-1mSv 1 n/a 0 0 0 0 0 0 0 0 0
Variant 3: Suspect occult fracture or other bone abnormality; radiographs nondiagnostic.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI elbow 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 elbow without IV contrast May be appropriate ☢☢ 0.1-1mSv 5 n/a 0 0 0 0 0 0 0 0 0
CT arthrography elbow Usually not appropriate ☢☢ 0.1-1mSv 2 n/a 0 0 0 0 0 0 0 0 0
MR arthrography elbow Usually not appropriate O 0 mSv O 0 mSv [ped] 2 n/a 0 0 0 0 0 0 0 0 0
US elbow Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Tc-99m MDP 3-phase bone scan elbow May be appropriate ☢☢☢ 1-10 mSv 4 n/a 0 0 0 0 0 0 0 0 0
MRI elbow 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
CT elbow without and with IV contrast Usually not appropriate ☢☢ 0.1-1mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT elbow with IV contrast Usually not appropriate ☢☢ 0.1-1mSv 1 n/a 0 0 0 0 0 0 0 0 0
Variant 4: Assess stability of osteochondral injury; radiographs nondiagnostic.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MR arthrography elbow Usually appropriate O 0 mSv O 0 mSv [ped] 9 n/a 0 0 0 0 0 0 0 0 0
MRI elbow 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 elbow Usually appropriate ☢☢ 0.1-1mSv 8 n/a 0 0 0 0 0 0 0 0 0
CT elbow without IV contrast Usually not appropriate ☢☢ 0.1-1mSv 3 n/a 0 0 0 0 0 0 0 0 0
US elbow Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Tc-99m MDP 3-phase bone scan elbow Usually not appropriate ☢☢☢ 1-10 mSv 1 n/a 0 0 0 0 0 0 0 0 0
MRI elbow 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 elbow without and with IV contrast Usually not appropriate ☢☢ 0.1-1mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT elbow with IV contrast Usually not appropriate ☢☢ 0.1-1mSv 1 n/a 0 0 0 0 0 0 0 0 0
Variant 5: Palpable soft-tissue mass; radiographs nondiagnostic.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI elbow 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
US elbow Usually appropriate O 0 mSv O 0 mSv [ped] 7 n/a 0 0 0 0 0 0 0 0 0
MRI elbow without IV contrast Usually appropriate O 0 mSv O 0 mSv [ped] 7 n/a 0 0 0 0 0 0 0 0 0
CT elbow without and with IV contrast Usually not appropriate ☢☢ 0.1-1mSv 2 n/a 0 0 0 0 0 0 0 0 0
CT arthrography elbow Usually not appropriate ☢☢ 0.1-1mSv 1 n/a 0 0 0 0 0 0 0 0 0
MR arthrography elbow Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Tc-99m MDP 3-phase bone scan elbow Usually not appropriate ☢☢☢ 1-10 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT elbow without IV contrast Usually not appropriate ☢☢ 0.1-1mSv 3 n/a 0 0 0 0 0 0 0 0 0
CT elbow with IV contrast Usually not appropriate ☢☢ 0.1-1mSv 3 n/a 0 0 0 0 0 0 0 0 0
Variant 6: Suspect chronic epicondylitis, refractory to empirical treatment; radiographs nondiagnostic.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI elbow 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 elbow Usually appropriate O 0 mSv O 0 mSv [ped] 8 n/a 0 0 0 0 0 0 0 0 0
MR arthrography elbow Usually not appropriate O 0 mSv O 0 mSv [ped] 2 n/a 0 0 0 0 0 0 0 0 0
MRI elbow without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 2 n/a 0 0 0 0 0 0 0 0 0
Tc-99m MDP 3-phase bone scan elbow Usually not appropriate ☢☢☢ 1-10 mSv 2 n/a 0 0 0 0 0 0 0 0 0
CT arthrography elbow Usually not appropriate ☢☢ 0.1-1mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT elbow without IV contrast Usually not appropriate ☢☢ 0.1-1mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT elbow without and with IV contrast Usually not appropriate ☢☢ 0.1-1mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT elbow with IV contrast Usually not appropriate ☢☢ 0.1-1mSv 1 n/a 0 0 0 0 0 0 0 0 0
Variant 7: Suspect collateral ligament tear; radiographs nondiagnostic.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MR arthrography elbow Usually appropriate O 0 mSv O 0 mSv [ped] 9 n/a 0 0 0 0 0 0 0 0 0
MRI elbow 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 elbow May be appropriate O 0 mSv O 0 mSv [ped] 6 n/a 0 0 0 0 0 0 0 0 0
Radiography elbow stress views May be appropriate ☢ <0.1 mSv 6 n/a 0 0 0 0 0 0 0 0 0
CT arthrography elbow May be appropriate ☢☢ 0.1-1mSv 5 n/a 0 0 0 0 0 0 0 0 0
CT elbow without IV contrast Usually not appropriate ☢☢ 0.1-1mSv 2 n/a 0 0 0 0 0 0 0 0 0
CT elbow without and with IV contrast Usually not appropriate ☢☢ 0.1-1mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT elbow with IV contrast Usually not appropriate ☢☢ 0.1-1mSv 1 n/a 0 0 0 0 0 0 0 0 0
Tc-99m MDP 3-phase bone scan elbow Usually not appropriate ☢☢☢ 1-10 mSv 1 n/a 0 0 0 0 0 0 0 0 0
MRI elbow 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
Variant 8: Suspect biceps tendon tear; radiographs nondiagnostic.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI elbow 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 elbow Usually appropriate O 0 mSv O 0 mSv [ped] 8 n/a 0 0 0 0 0 0 0 0 0
CT arthrography elbow Usually not appropriate ☢☢ 0.1-1mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT elbow without IV contrast Usually not appropriate ☢☢ 0.1-1mSv 1 n/a 0 0 0 0 0 0 0 0 0
MR arthrography elbow Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Tc-99m MDP 3-phase bone scan elbow Usually not appropriate ☢☢☢ 1-10 mSv 1 n/a 0 0 0 0 0 0 0 0 0
MRI elbow 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
CT elbow without and with IV contrast Usually not appropriate ☢☢ 0.1-1mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT elbow with IV contrast Usually not appropriate ☢☢ 0.1-1mSv 1 n/a 0 0 0 0 0 0 0 0 0
Variant 9: Suspect nerve abnormality; radiographs nondiagnostic.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI elbow 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 elbow Usually appropriate O 0 mSv O 0 mSv [ped] 8 n/a 0 0 0 0 0 0 0 0 0
CT arthrography elbow Usually not appropriate ☢☢ 0.1-1mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT elbow without IV contrast Usually not appropriate ☢☢ 0.1-1mSv 1 n/a 0 0 0 0 0 0 0 0 0
MR arthrography elbow Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Tc-99m MDP 3-phase bone scan elbow Usually not appropriate ☢☢☢ 1-10 mSv 1 n/a 0 0 0 0 0 0 0 0 0
MRI elbow without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 2 n/a 0 0 0 0 0 0 0 0 0
CT elbow without and with IV contrast Usually not appropriate ☢☢ 0.1-1mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT elbow with IV contrast Usually not appropriate ☢☢ 0.1-1mSv 1 n/a 0 0 0 0 0 0 0 0 0
Variant 10: Elbow stiffness; suspect heterotopic ossification/osteophytosis by radiography. Next test.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
CT elbow without IV contrast Usually appropriate ☢☢ 0.1-1mSv 9 n/a 0 0 0 0 0 0 0 0 0
MRI elbow 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 arthrography elbow Usually not appropriate ☢☢ 0.1-1mSv 1 n/a 0 0 0 0 0 0 0 0 0
MR arthrography elbow Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
US elbow Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Tc-99m MDP 3-phase bone scan elbow May be appropriate ☢☢☢ 1-10 mSv 5 n/a 0 0 0 0 0 0 0 0 0
MRI elbow 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
CT elbow without and with IV contrast Usually not appropriate ☢☢ 0.1-1mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT elbow with IV contrast Usually not appropriate ☢☢ 0.1-1mSv 1 n/a 0 0 0 0 0 0 0 0 0
Variant 11: Suspect inflammatory arthritis or bursitis; radiographs obtained.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI elbow 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 elbow without IV contrast Usually appropriate O 0 mSv O 0 mSv [ped] 8 n/a 0 0 0 0 0 0 0 0 0
US elbow Usually appropriate O 0 mSv O 0 mSv [ped] 7 n/a 0 0 0 0 0 0 0 0 0
Tc-99m MDP 3-phase bone scan elbow Usually not appropriate ☢☢☢ 1-10 mSv 3 n/a 0 0 0 0 0 0 0 0 0
CT arthrography elbow Usually not appropriate ☢☢ 0.1-1mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT elbow without and with IV contrast Usually not appropriate ☢☢ 0.1-1mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT elbow with IV contrast Usually not appropriate ☢☢ 0.1-1mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT elbow without IV contrast Usually not appropriate ☢☢ 0.1-1mSv 1 n/a 0 0 0 0 0 0 0 0 0
MR arthrography elbow Usually not appropriate O 0 mSv O 0 mSv [ped] 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.