American College of Radiology
ACR Appropriateness Criteria®

Chronic Foot Pain

Variant 1: Chronic foot pain of unknown etiology. First study.
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
US foot 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 foot Usually not appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
MRI foot 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
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
MRI foot 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 2: Adult or child. Painful rigid flat foot. Radiographs unremarkable or equivocal and clinical concern for tarsal coalition.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
CT foot without IV contrast Usually appropriate ☢ <0.1 mSv ☢☢ 0.03-0.3 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
Tc-99m bone scan foot Usually not appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 n/a 0 0 0 0 0 0 0 0 0
US foot Usually not appropriate O 0 mSv O 0 mSv [ped] 2 n/a 0 0 0 0 0 0 0 0 0
MRI foot 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 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
Variant 3: Radiographs unremarkable or equivocal and clinical concern for complex regional pain syndrome type I.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Tc-99m 3-phase bone scan foot Usually appropriate ☢☢☢ 1-10 mSv 8 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] 2 n/a 0 0 0 0 0 0 0 0 0
MRI foot without IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 2 n/a 0 0 0 0 0 0 0 0 0
US foot Usually not appropriate O 0 mSv O 0 mSv [ped] 2 n/a 0 0 0 0 0 0 0 0 0
MRI foot 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 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
Variant 4: Adult or child. Radiographs noncontributory. Pain and tenderness over head of second metatarsal and clinical concern for Freiberg infraction.
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
CT foot without and with IV contrast Usually not appropriate ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 2 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] 2 n/a 0 0 0 0 0 0 0 0 0
US foot Usually not appropriate O 0 mSv O 0 mSv [ped] 2 n/a 0 0 0 0 0 0 0 0 0
Tc-99m bone scan foot Usually not appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 n/a 0 0 0 0 0 0 0 0 0
MRI foot without IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 2 n/a 0 0 0 0 0 0 0 0 0
MRI foot 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 foot with IV contrast Usually not appropriate ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 2 n/a 0 0 0 0 0 0 0 0 0
Variant 5: Pain and tenderness over tarsus, unresponsive to conservative therapy. Radiographs showed accessory ossicle.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
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
Tc-99m bone scan foot May be appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 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] 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] 3 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] 2 n/a 0 0 0 0 0 0 0 0 0
US foot Usually not appropriate O 0 mSv O 0 mSv [ped] 2 n/a 0 0 0 0 0 0 0 0 0
MRI foot 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
Variant 6: Radiographs unremarkable, equivocal, or further diagnostic information needed. Clinical concern for inflammatory arthopathy, including rheumatoid arthritis.
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] 8 n/a 0 0 0 0 0 0 0 0 0
US foot May be appropriate O 0 mSv O 0 mSv [ped] 5 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
Tc-99m bone scan foot Usually not appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 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 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
Variant 7: Localized pain at the plantar aspect of the heel. Radiographs unremarkable or equivocal. Clinical concern for plantar fasciitis.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
CT foot without and with IV contrast Usually not appropriate ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 3 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
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
US foot 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 foot Usually not appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 n/a 0 0 0 0 0 0 0 0 0
MRI foot 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 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
Variant 8: Burning pain and paresthesias along the plantar surface of the foot and toes. Radiographs unremarkable or equivocal. Clinical concern for tarsal tunnel syndrome.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
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
MRI foot without and with IV contrast Usually appropriate O 0 mSv O 0 mSv [ped] 7 n/a 0 0 0 0 0 0 0 0 0
US foot May be appropriate O 0 mSv O 0 mSv [ped] 5 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] 3 n/a 0 0 0 0 0 0 0 0 0
Tc-99m bone scan foot Usually not appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 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 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
Variant 9: Pain in the 3-4 web space with radiation to the toes. Radiographs unremarkable or equivocal. Clinical concern for Morton neuroma.
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
US foot 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] 7 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] 2 n/a 0 0 0 0 0 0 0 0 0
Tc-99m bone scan foot Usually not appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 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] 2 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
Variant 10: Athlete with pain and tenderness over tarsal navicular. Radiographs unremarkable or equivocal. Clinical concern for stress injury or occult fracture.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
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] 6 n/a 0 0 0 0 0 0 0 0 0
Tc-99m bone scan foot Usually not appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 n/a 0 0 0 0 0 0 0 0 0
US foot Usually not appropriate O 0 mSv O 0 mSv [ped] 2 n/a 0 0 0 0 0 0 0 0 0
MRI foot 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 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
Variant 11: Radiographs unremarkable or equivocal and with persistent clinical concern for tendinopathy.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
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
US foot Usually appropriate O 0 mSv O 0 mSv [ped] 7 n/a 0 0 0 0 0 0 0 0 0
MRI foot 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 foot without and with IV contrast Usually not appropriate ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 3 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
Tc-99m bone scan foot Usually not appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 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
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.