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Appropriateness Criteria

Variant 1: Adult. Chronic foot pain. Unknown etiology. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography foot Usually appropriate Moderate ☢ <0.1 mSv ☢ <0.03 mSv [ped] 9 9 1 0 0 0 0 0 0 0 13
References Study Quality
14 (18894612) 4
16 (25805712) 4
17 (23811947) 4
19 (16697701) 2
18 (20439021) 4
15 (8356270) 4
12 (2358259) 4
13 (30379105) 4
US foot Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 3 3 3 2 3 0 5 0 0 1 0
Image-guided anesthetic +/- corticosteroid injection foot or surrounding structures Usually not appropriate Expert Consensus Varies Varies 1 1 13 1 0 0 0 0 0 0 0
MRI foot without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 10 2 1 0 1 0 0 0 0
MRI foot without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 8 3 1 1 1 0 0 0 0
CT foot with IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 9 2 2 0 0 0 1 0 0
CT foot without and with IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 10 1 2 0 0 1 0 0 0
CT foot without IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 8 3 0 3 0 0 0 0 0
Bone scan foot Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 10 1 1 0 1 0 0 1 0
Variant 2: Adult. Chronic foot pain. Suspect tendon or ligament or fascia or muscle or other soft tissue origin. Radiographs negative or indeterminate. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US foot Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 1 0 0 2 1 3 6 1
References Study Quality
2 (34642777) 4
52 (25466436) 4
51 (16819605) 3
49 (25027985) 2
50 (28398696) 2
48 (33135090) 4
42 (18064426) 3
47 (19664484) 4
40 (25809742) Good
43 (16040817) 1
46 (27957702) 4
44 (-3145751) 3
45 (-3145753) 2
34 (35533558) Good
21 (20489099) 2
28 (31498747) 4
MRI foot without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 1 0 0 0 0 0 4 9
References Study Quality
2 (34642777) 4
30 (36773427) 4
41 (9114115) 3
40 (25809742) Good
28 (31498747) 4
29 (30063368) 4
33 (22727342) 2
32 (20964964) 3
37 (10551246) 3
38 (9016241) 3
35 (20308514) 4
36 (12668744) 4
39 (37353000) 3
34 (35533558) Good
27 (8372200) 4
25 (17420632) 3
31 (10470906) 4
26 (11706214) 4
Image-guided anesthetic +/- corticosteroid injection foot or surrounding structures May be appropriate Limited Varies Varies 5 5 0 3 0 4 6 1 0 0 0
References Study Quality
24 (9240528) 4
23 (31068007) 4
22 (11159075) 4
MRI foot without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 7 0 3 0 2 2 0 0 0
References Study Quality
27 (8372200) 4
26 (11706214) 4
25 (17420632) 3
CT foot with IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 2 2 7 3 1 0 1 1 1 0 0
CT foot without and with IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 8 3 0 1 0 2 0 0 0
CT foot without IV contrast Usually not appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 8 2 0 0 3 0 1 0 0
References Study Quality
21 (20489099) 2
Bone scan foot Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 8 6 0 0 0 0 0 0 0
References Study Quality
20 (18806575) 4
Variant 3: Adult. Chronic foot pain. Suspect occult fracture or painful ossicles or pain of other osseous origin. Radiographs negative or indeterminate. Next imaging study.
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 Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 1 2 11
References Study Quality
83 (30685010) 4
82 (19038613) 4
80 (27888854) 4
81 (27885856) 4
78 (9765133) 4
79 (34704114) 4
76 (22078792) 4
73 (8571860) 4
65 (11858605) 4
75 (26888876) 2
64 (29876712) 3
74 (26557590) 3
77 (29228800) 4
60 (30973781) 4
26 (11706214) 4
15 (8356270) 4
CT foot without IV contrast Usually appropriate Strong ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 8 8 0 0 0 1 0 1 3 5 4
References Study Quality
73 (8571860) 4
72 (15018183) 4
69 (19038614) 4
70 (21817003) 3
68 (12627621) 4
71 (8079860) 4
66 (15333345) 3
65 (11858605) 4
67 (29679212) Good
64 (29876712) 3
60 (30973781) 4
US foot May be appropriate Limited O 0 mSv O 0 mSv [ped] 4 4 1 3 3 4 3 0 0 0 0
References Study Quality
61 (15230772) 4
85 (22506252) 4
84 (10477883) 4
Image-guided anesthetic +/- corticosteroid injection foot or surrounding structures May be appropriate Limited Varies Varies 5 5 0 1 2 2 9 0 0 0 0
References Study Quality
60 (30973781) 4
MRI foot without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 7 0 4 1 0 2 0 0 0
CT foot with IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 2 2 7 3 0 0 3 1 0 0 0
CT foot without and with IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 8 2 0 1 2 0 1 0 0
Bone scan foot Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 0 3 5 2 2 2 0 0 0
References Study Quality
63 (29348982) 4
62 (25210293) 4
59 (1424449) 4
61 (15230772) 4
58 (3806228) 4
60 (30973781) 4
27 (8372200) 4
54 (21540716) 4
15 (8356270) 4
55 (7633586) 2
57 (11595853) 4
53 (30788224) 4
56 (31507140) 3
Variant 4: Adult. Chronic foot pain. Suspect osteochondral lesion or cartilage abnormality or degenerative joint disease or pain of other articular origin. Radiographs negative or indeterminate. Next imaging study.
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 Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 2 1 11
References Study Quality
87 (36737484) 4
CT foot without IV contrast Usually appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 7 7 0 0 0 0 0 1 8 5 0
References Study Quality
91 (30383405) 2
90 (32995345) 4
89 (35219362) 4
88 (33259992) 3
87 (36737484) 4
US foot May be appropriate Strong O 0 mSv O 0 mSv [ped] 4 4 1 1 2 4 4 2 0 0 0
References Study Quality
10 (37236743) 4
98 (34378811) 2
96 (28478580) 4
97 (27999984) 1
87 (36737484) 4
Image-guided anesthetic +/- corticosteroid injection foot or surrounding structures May be appropriate Limited Varies Varies 5 5 0 0 1 1 9 3 0 0 0
References Study Quality
24 (9240528) 4
95 (8751679) 4
92 (19755074) 4
93 (21940584) 4
94 (15664573) 4
MR arthrography foot May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 0 1 2 10 0 1 0 0
References Study Quality
87 (36737484) 4
MRI foot without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 6 2 1 2 1 1 1 0 0
CT foot with IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 2 2 7 2 2 1 0 1 1 0 0
CT foot without and with IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 8 2 1 1 1 0 1 0 0
Bone scan foot Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 10 2 2 0 0 0 0 0 0
References Study Quality
86 (37953864) 4
Variant 5: Adult. Chronic foot pain. Suspect foreign body. Radiographs negative or indeterminate. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US foot Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 1 2 11
References Study Quality
114 (14682417) 4
113 (1887037) 4
111 (9423650) 2
109 (11553831) 4
110 (7594298) 4
112 (11312171) 4
99 (11856673) 4
MRI foot without and with IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 0 0 1 7 6 0 0 0
References Study Quality
102 (21442560) 4
101 (24951233) 4
MRI foot without IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 1 0 0 0 1 8 2 2 0
References Study Quality
108 (12740473) 4
107 (9215474) 4
99 (11856673) 4
101 (24951233) 4
105 (7618565) 4
106 (21886538) 4
CT foot with IV contrast May be appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 5 5 0 1 1 2 10 0 0 0 0
References Study Quality
99 (11856673) 4
CT foot without IV contrast May be appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 5 5 0 0 1 4 9 0 0 0 0
References Study Quality
104 (33136481) 4
103 (23264199) 4
99 (11856673) 4
101 (24951233) 4
100 (20100917) 2
102 (21442560) 4
Image-guided anesthetic +/- corticosteroid injection foot or surrounding structures Usually not appropriate Expert Consensus Varies Varies 1 1 11 1 2 0 0 0 0 0 0
CT foot without and with IV contrast Usually not appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 2 2 7 1 2 1 2 0 1 0 0
References Study Quality
99 (11856673) 4
Bone scan foot Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 10 4 0 0 0 0 0 0 0
Variant 6: Adult. Chronic foot pain. Suspect Baxter neuropathy or complex regional pain syndrome or entrapment syndrome or other neurogenic origin. Radiographs negative or indeterminate. Next imaging study.
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 Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 1 6 7
References Study Quality
125 (19703848) 2
124 (26284303) 4
123 (21415181) 4
US foot May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 0 0 3 6 1 4 0 0
References Study Quality
2 (34642777) 4
128 (9798855) 4
127 (23980227) 3
124 (26284303) 4
126 (29791963) 4
Image-guided anesthetic +/- corticosteroid injection foot or surrounding structures May be appropriate (Disagreement) Expert Opinion Varies Varies 5 5 0 3 1 4 3 3 0 0 0
References Study Quality
116 (21600446) 4
117 (27341442) 4
MRI foot without and with IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 5 5 0 0 0 1 8 2 3 0 0
References Study Quality
122 (30322495) 4
121 (32534352) 2
120 (7892471) 3
119 (17515744) 2
115 (22177715) Inadequate
118 (24161450) 4
3-phase bone scan foot May be appropriate Limited ☢☢☢ 1-10 mSv 5 5 0 0 1 1 8 2 1 1 0
References Study Quality
115 (22177715) Inadequate
CT foot with IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 10 3 1 0 0 0 0 0 0
CT foot without and with IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 8 1 0 2 1 1 1 0 0
CT foot without IV contrast Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 2 2 7 2 0 1 2 2 0 0 0
Bone scan foot Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 8 0 3 2 0 0 1 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.